Mental Health Clinical Experience: Nursing Diagnoses, Patient Assessment, And Interventions

Purpose of the Assignment

The patient is a 45-year old white American female who presented to the NNAMHS due to legal hold for SI with a plan to jump from the golden gate bridge. The patient describes being depressed since she was emotionally and sexually abused by her stepfather from age 9 to age 13 and has a history of an abusive marriage. Since then the patient has experienced increasing depression and suicidal thoughts. The report of 3 suicide attempts of suicide and depression made her be presented at the NNAMHS. The patient is bisexual and has no religious belief. She has been under detox/rehab and psychiatric hospitalization. A positive history of substance dependence – sober since 26th Sept.

Suicidal Thoughts and depression with anxiousness

The patient is not quite alert, not so-oriented, and while being cooperative with the interview. The patient describes herself as having a short temper but claims she is a peaceful person. The patient has an affect as appropriate, congruent to topics and her mood was tearful. The speech of the patient is at a rapid rate with normal volume and articulation and tone. Her thought process is at a rapid rate and tangential. The patient appears good with appropriate effect and mood-congruent. Her mod is depressed at the time of the interview and depressed. The patient depicts no signs of thought process but reported raced thoughts sometimes. She is able to verbalize her feelings and is goal-oriented stating she wants to get into rehab and find housing for herself. The patient describes as “depressed and anxious on the scale as 7 out of 10. The patient reports suicidal ideation but acknowledges that her thoughts are slightly improved. However, does not report any improvement in auditory and visual cognition. Pt describes strengths as being honest, punctual, loyal, hardworking, creative, future-oriented to get clean. Pt feels her weakness is depression and her short temper. Her grooming and hygiene are fair, dresses in clean facility attire, short hair appears clean. The patient presents with depressed affect, the mood appears congruent with affect, speech and tone WNL, thought content and process are organized and linear. Pt denies SI without a plan and states “I feel better now, and I choose me.” Pt is future and goal-oriented to get clean, get a job, obtain housing and work on issues from her past that cause her to feel hopeless and helpless at times. She reports a past history of high energy, elevated mood, hyper-focused behavior, impulsivity, ability to go days without sleep. She reports difficulty managing her mood at a young age. Noted to have rapid speech, a flight of ideas, she reports that’s she believes that she is in touch with these after the afterlife. She admits to positive visual hallucinations to include seeing shadows but states that this is generally during times of high stress.

Overview of the Patient’s Condition

Treatment 3 previous times in NNAMHS and 4 to 6 in San Louis Obispo for depression. 3 suicide attempts: first by way of an overdose after losing custody of her daughter to her mother, second in prison by way of hanging, and third when tried to jump from a bridge in Washington state. Previous history of depression, suicidal attempts. Last alcohol use on 26th September. The patient first drinks alcohol at age 9 and reports it has been problematic since the age of 13. No family history of alcohol use. The patient has used cocaine when she started using meth at the age of 24 and relays she used it every day since and is a non-smoker.

The patient reports herself as bisexual and with a preference for women. Pt disclosed she has married twice with first lasting 7years and reports they divorced because her husband could not stay out of prison. Pt second marriage ended with the death of her wife due to complications from her diabetes along with alcohol abuse. Pt is currently homeless and describes the last couple of years as just floating around CA couch surfing. Pt worked as a cashier and has also cleaned houses and identifies time she has worked as the best times of her life. Pt describes strengths as being honest, punctual, loyal, hardworking, creative, future-oriented to get clean. Pt feels her weakness is depression and her short temper. Pt denies SI without a plan and states “I feel better now, and I choose me.” Pt is future and goal-oriented to get clean, get a job, obtain housing and work on issues from her past that cause her to feel hopeless and helpless at times. The patient wants to get into a treatment center and needs to change her Medi-Cal to Medicaid and is waiting for a DD214 and social security card. No family and friends and not very active in life right now.

Hx of anemia, HTN, PTSD, depression. The patient reported medication of past chronic anemia and expressed that her chronic condition is destroying her. Veins due to IV drugs due to chest post was placed for future medicinal needs.  Pain scale 0/10. Vital signs stable. Admission labs within normal limits, AMP/Meth = negative, HCG-QUAL= negative. HCG=negative.

History Previous history of depression, suicidal attempts. Last alcohol use on 26th September.

Patient/Assessment Findings Treatment 3 previous times in NNAMHS and 4 to 6 in San Louis Obispo for depression. 3 suicide attempts: first by way of an overdose after losing custody of her daughter to her mother, second in prison by way of hanging, and third when tried to jump from a bridge in Washington state.

Medications 1. Aripiprazole 2. Doxepin

Laboratory/Diagnostics AMP/Meth = negative, HCG-QUAL= negative. HCG=negative

Nursing Diagnostics 1. giving a protected domain: Removing possibly harmful articles, keeps the patient from acting towards unexpected driving forces. 2. starting a no-suicide contract-This strategy sets up authorization to discuss the subject.

Interventions (Rationale) 1. Give a protected environment: Weapons and pills ought to be removed by partners, family members, or nurses. 2. Make a verbal or composed agreement expressing that the patient won’t follow up on the drive to do self-hurt.

Conversation with the patient to assess the potential for self-hurt (Erbacher & Singer, 2017).	Patients considering suicide may show verbal and physical signs about their expectations to take their life.
? “Have you at any point considered hurting yourself?”	Suicide ideation is simply a way of pondering killing themselves. The patient’s risk of suicide advances as these thoughts become increasingly common.
? “Have you at any point tried suicide?”	The patient’s status of suicide chance is recognized if there is a history marked by before suicide attempts.
? “Do you recently consider killing yourself?”	This takes into consideration the individual to talk about sentiments and issues transparently.
? “What are your arrangements with respect to killing yourself?”	Referring to an arrangement and the capacity to complete it extraordinarily increasing the risk of suicide. The more painful the arrangement, the more genuine the risk of suicide.

Medication Generic & Trade name Drug Class dose, route, time	Mechanism of action	Why is THIS patient receiving this medication	Contraindications/Interactions	Adverse Reactions/ Side Effects	Nursing Implications
Amitriptyline,   25– 150 mg/day)	Antidepressant action.	For depression	May increase the risk of suicide attempt specifically at the time of dose early treatment or adjustment	lethargy, sedation.	Monitor mental status (orientation, mood behavior) frequently. Assess for suicidal tendencies, especially during early therapy.
FLUoxetine Trade name: PROzac —20 mg/day in the morning. After several weeks, may increase by 20 mg/day at weekly intervals	Antidepressant action. Decreased behaviors associated with suicidal thoughts	Posttraumatic stress disorder (PTSD)	Hypersensitivity; Concurrent use of MAO inhibitors or MAOlike drugs (linezolid or methylene blue)	anxiety, drowsiness, headache, insomnia, nervousness	Assessment of suicidal tendencies, at the time of early therapy. Restrict amount of drug available to patient.
Desipramine Trade Name: Norpramin	Antidepressant action. Potentiates the effect of serotonin and norepinephrine	Depression	May  increase risk of suicide attempt/ideation especially during early treatment or dose adjustment	drowsiness, fatigue	Monitor mental status (orientation, mood, behavior) frequently. Assess for suicidal tendencies, especially during early therapy.

The nurse whether beginner or experienced ought to have the option to perceive when a circumstance is over their competency and what to suggest so the urgency of the circumstance is recognized (Kusheba & Mulvihill, 2018). Nurses have an obligation to the patient to ensure their category and keep up willingness and yet keep up safety and furnish them with the most ideal consideration. Fitting appraisal, interventions, and assessment of suicide risk ought to be evaluated on the present patient upon hospital affirmation and occasionally from that point. The nurse should be educated if a patient”s status had changed, particularly if the nurse feels it is beyond their competency level (Harris, Lello & Willcox, 2016). Knowing the patient is equipped, understanding the nursing code of ethical proclamation, and ethical standards can enable the nurse to make his/her ethical choice. The nurse ought to get directions in observing the suitable reaction to the patients communicating self-destructive thoughts and what their jobs and obligations are (Duffey, 2017).

1. The nurses need evidence-based clinical consideration practices and norms, for example, those created by the Emergency Nurses Association for suicide hazard evaluation (Kleiman & Nock, 2019).
2. Healthcare clinics need to execute such principles and create preparing that consolidates the rules. Choice support devices that assist nurses with understanding their jobs and reactions, for example, the McKesson Interqual® Behavioral Health Decision Support Tool, permit presently experiencing people thinking about suicide to be prepared and able in their abilities (Spillane, Matvienko-Sikar, Larkin, Corcoran & Arensman, 2018). Yearly survey with preparing for suicide screening would keep on giving nurses an approach, in a similar way as cardiopulmonary revival review and practice (Horgan, Kelly, Goodwin & Behan, 2018).

Homelessness is a healthcare disparity experienced by the client. For the patient the lack of composed and stable housing contribute towards such type of disparities. Additionally, having direct relation with the lack of employment as well as income, homelessness is also related with increased barriers towards education, food security, and decreased public safety. As compared to other people, homeless patients have shorter life expectancies, which are attributable towards increased rates of substance abuse, alcohol, and suicidal attempts (White & Stubblefield-Tave, 2016).

References

Duffey, P. (2017). Implementing the Clinical Nurse Leader Role in a Large Hospital Network. Nurse Leader, 15(4), 276-280. doi: 10.1016/j.mnl.2017.03.014

Erbacher, T., & Singer, J. (2017). Suicide Risk Monitoring: the Missing Piece in Suicide Risk Assessment. Contemporary School Psychology, 22(2), 186-194. doi: 10.1007/s40688-017-0164-8

Harris, K., Lello, O., & Willcox, C. (2016). Reevaluating Suicidal Behaviors: Comparing Assessment Methods to Improve Risk Evaluations. Journal Of Psychopathology And Behavioral Assessment, 39(1), 128-139. doi: 10.1007/s10862-016-9566-6

Horgan, A., Kelly, P., Goodwin, J., & Behan, L. (2018). Depressive Symptoms and Suicidal Ideation among Irish Undergraduate College Students. Issues In Mental Health Nursing, 39(7), 575-584. doi: 10.1080/01612840.2017.1422199

Kleiman, E., & Nock, M. (2019). New directions for improving the prediction, prevention, and treatment of suicidal thoughts and behaviors among hospital patients. General Hospital Psychiatry. doi: 10.1016/j.genhosppsych.2019.06.002

Kusheba, J., & Mulvihill, K. (2018). A Patient?s Suicidal Ideations and a Clinical Nurse Leader?s Responsibility. Journal Of Hospice & Palliative Nursing, 20(6), 512-518. doi: 10.1097/njh.0000000000000501

Spillane, A., Matvienko-Sikar, K., Larkin, C., Corcoran, P., & Arensman, E. (2018). What are the physical and psychological health effects of suicide bereavement on family members? An observational and interview mixed-methods study in Ireland. BMJ Open, 8(1), e019472. doi: 10.1136/bmjopen-2017-019472

White, A., & Stubblefield-Tave, B. (2016). Some Advice for Physicians and Other Clinicians Treating Minorities, Women, and Other Patients at Risk of Receiving Health Care Disparities. Journal Of Racial And Ethnic Health Disparities, 4(3), 472-479. doi: 10.1007/s40615-016-0248-6