The Impact Of The Major Depressive Disorder On A Person's Life
This essay will focus in the long-term condition of depression analysing how depression can impact on a person’s life and the people that surround the patient. The nursing process will be explained as well as information around treatment and care planning. The use and implementation of tools to aid and highlight patients’ needs on the ward will be described. For the purpose of this assignment, I will use the case of patient B. Names and personal information have been anonymised to protect patient confidentiality as required by the General Data Protection Regulation (GDPR) (Article 4, 2018), Data Protection Act (2018) and NMC code of practice (2018).
According with the World Health Organization (WHO), Depression is defined as a common mental disorder that affect more than 264 million people in the world. It is presented by persistent low mood and a lack of interest in pleasant activities (Depression, 2020). The person with depression is likely to suffer from tiredness because lack of sleep and concentration are common symptom of depression. The consequences of a major depressive disorder can affect in a severe way the person’s everyday life (Depression, 2020). Patients describe depression as a continuous unhappiness and the inability to experience positive emotions, a feeling of hopelessness and pessimistic thoughts about themselves, their condition and the future (David et al, 2013). It is difficult to determine the pathophysiology of the major depressive disorder; elements as Glucocorticoid neurotoxicity, glutamatergic toxicity, decreased neurotrophic factors and decreased neurogenesis have been suggested as possible mechanisms explaining brain volume loss in depression (Hasler, 2010). However, the pathophysiological reason of major depressive disorder it is not completely agreed.
The subject of this case study is Patient B (name changed for confidentiality, NMC, 2018) Mr B is a 50-year-old male of white British origin who is currently an inpatient on an acute unit in a Mental Health Ward. He has a diagnosis of severe depression. Patient B has been admitted to the ward due to ongoing active suicidal ideation and a recent attempt to end his life. This situation has impacted on his daily living and on his physical health as he has been self-neglecting himself resulting in poor nutritional intake.
Patient B has had several admissions to mental health hospitals for more than 20 years. He has been treated with different anti-depressants, initially with good effect but with less effect long term.
It is researched that 90 per cent of people suffering with depression are under treatment in a primary health care, and the rest require a psychiatric admission (Scott et al., 1997).
There are a different number of treatment options for patients with depression. The most common interventions are talking therapies, anti-depressant therapy and electro convulsive therapy (ECT). This therapy is offered to patients with severe depression or for those suffering from depressions with psychotic features (Ian Norman et al., 2004). Patients considered for electro convulsive therapy are usually treatment resistant, patients that did not respond to other alternative treatments.
Patient B is now is starting to be treated with ECT. This treatment consists in the passage of an electrical current through the brain with the purpose of induce a seizure (Ian et al., 2004).
Before the medical team recommended ECT for Patient B, he was under treatment with two different an anti-depressant. The first antidepressant was Lithium and the second was Fluoxetine (Prozac), (NHS Medicines, 2020) . Lithium has two different effects (NHS Medicines, 2020). The first effect is neuroprotective and the second effect neuroproliferative, these effects are evidenced by conservation of grey matter. (Guzman, 2019).
Fluoxetine is a Serotonin reptake inhibitor (SSRIs) that have the effect to increase the amount of serotonin available in the brain. Serotonin is chemical neurotransmitter that helps with the synapse (Ian et al., 2004).
The ECT treatment did not work for patient B. Regularly the patient refused weekly blood tests to check renal and thyroid function (NHS Borders, 2011). In addition, he was not happy with other side effects such a tremor, diarrhoea, speech difficulties and headaches.
The implementation of the Orlando’s nursing process (1961) promotes holistic approach to caring for the patient. Orlando (1961) stated that knowing your patients and understand their necessities using your own perceptions it is a fundamental part of the care, this can be implemented using the organisational process.
Roper Logan and Tierney’s nursing process model of activities of daily living (RLT,2000) will be used in this essay in order to create a clear and concise assessment of Patient B, as well as being able to draw up and achievable care plan. The RLT activities for daily living (ADL) model uses the same organisational Orlando’s processes of assessment, diagnosis, planning, implementing and evaluation to structure the basis for a holistic care plan. RLT model is generally used in the UK as a way of evaluating levels of independence by looking at twelve basic human requirements (Williams, 2017). These requirements are maintaining a safe environment, communication, breathing, eating and drinking, elimination, washing and dressing, controlling temperature, mobilisation, working and playing, expressing sexuality, sleeping and dying. The RLT model focuses mainly in patient’s ADLs and those factors affecting these activities. The RLT considers biological and psychological factor and how these are applied in nursing in the day to day life. This model will also be used in conjunction to the nursing process in order to identify what key elements are affecting patient B preventing his recovery.
When patient B was admitted into hospital, a full chronological patient’s history was completed to know what helped Mr B in the past in not in order to assure that the higher possible care could be provide. All information related to patient B was recorded to get to know him. The collection of information is one of the steps of the assessment and initiate the “nursing process” (Ian et al., 2014). Baker has described mental health nursing assessment as the decision-making process based in the accumulation of important information that contributes to a whole evaluation of an individual and his condition (Barker, 1997). The necessities of a patient, which have been recognized trough the assessment process, which can be achieved by social services or health services, form the basis of a care plan. This care plan must include a content of the goals to be achieved, a statement of any actions assumed, and particular criteria against which and assessment of progression can be made (Ward, 1992). For patient B the nursing process started with an initial assessment looking for relevant data collection, subjective and objectively, with the purpose to create an assessment (Tammy et al., 2019).
Through this case we will be looking at how the long-term major depressive disorder condition impact across daily life and social interactions. Based in the Roper Logan and Tierney (RLT) model of daily living, the nursing team has pinpointed three different areas in which patient B’s daily living has been affected. These areas include personal care, eating and fluid ingestion (nutritional intake) and maintaining a safe environment. Previously to the beginning of the assessment, the patient should be made aware of why they are being assessed and consent to the process (NMC, 2018)
Because Patient B was having ongoing active suicidal thoughts which were aggravating in frequency the aim to maintaining a safe environment was one of the main factors that affects patient B’s recuperation.
Patient B’s suicidal ideation was one of the principal factors pertaining to his hospital admission. (David et al.,2014) state that the risk of suicide could be magnified in the early stages of antidepressant treatment, close monitoring is critical in this stage. Patients may feel less hopeless and less lethargic but still depressed therefore more prone to act. Patient B is currently detained on a section 3 of the Mental Health Act (1983). Section 3 is defined as admission for assessment, patients may be detained for a period not exceeding 180 days (Mental Health Act, 1983).
Other reason for patient B detention in the hospital was that he was suffering of recurrent episodes of major depressive disorder. Benjamin et al, highlight that the main problem diagnosing recurrent major depressive disorder is choosing the criteria to designate the resolution of each period of depression. Long term health conditions, also named to as chronic conditions, are defined by the World Health Organisation as “health problems that persist across time and require some degree of health care management” (WHO, 2002).
When patient B was admitted into the ward, he accepted to fill a patient health questionnaire assessment (PHQ-9). This assessment is a tool that helps to elaborate a criteria-based diagnoses of depressive and other mental disorders that frequently come across in primary care (Kroenke et al., 2001). Patient B scored more than 25 in the PHW-9 assessment, which indicates severe depression.
Using the RLT model, another risk area identified was Patient B’s ingestion (nutritional intake). Consequently, a malnutrition universal screening tool (MUST) was undertaken. MUST is an instrument that helps medical professionals to identify adults who are malnourished or in a risk of malnutrition, obese or under-nutrition. It also includes guidelines of how to manage malnutrition. Must contains management procedures which can be used to create a care plan. (BAPEN, 2011).
Using this tool with patient B, he scored a 4, this score means that he is in a high risk of malnutrition. In this instance a MUST tool was used to evaluate Patient B’s condition regarding his nutrition. The ‘Malnutrition Universal Screening Tool’ (‘MUST’) was created by the Malnutrition Advisory Group. It is the most usually used screening instrument in the UK. It is also used in numerous countries in Europe (BAPEN, 2011). With the result of this tool, the nurse team was able to work in the next steps into Patient B care plan and aim all his nutritional necessities.
Due to Patient B’s long-term condition of depression, he has been often self-isolated in his room, lethargic, catatonic at times and with no motivation to attend his personal care. When patient B is in a catatonic presentation the characteristic signs are mutism, negativism, posturing, rigidity, staring, posturing. (David et al., 2014), state that the frequent causes of catatonia in a mood disorder are commonly related to mania or depression. Often referred as manic or depressive stupor. The effective mutism is normally connected with a pre-existent personality disorder.
Patient B was unable to attend the most basic personal care, like washing, tooth cleaning, dressing, etc.. Personal care area was identified through the RLT tool. This lack of motivation to attend his personal care affected his confidence, and created a loop, because he was spending more time self-isolated in his room and unable to make any progress.
The care team started to plan possible interventions with the aim to support patient B’s recovery. This stage is named as the planning stage, this process looks at how proceeding is identified to minimize, solve or prevent the patient’s problems, while supporting the patient’s advantages in an organised, goal-directed process (Kozier et al, 2008).
The strategy elaborated by the care team was reflected in a care plan, this care plan was produced with Patient B’s participation. In the process of completing a care plan various smart goals were drawn up. A SMART goal must be specific, measurable, achievable, realistic and timely. A SMART goal incorporates all of these criteria to help focus your efforts and increase the chances of achieving that goal (CFI, Undated).
In relation to Patient B’s Nutrition, the assessment reflected his actual condition and the future goals. The nursing team decided to commence to monitor the patient using a food and fluid chart. The first the aim of the smart goal was for patient B to reach a healthy weight. This was measurable by recording a starting weight in the starting plan up and keep measuring through the proceeding. This action can be called the “doing” part of the nursing process.
The medical and nursing teams suggested and encouraged patient B to start doing light physical exercises, like short walks, or play games as table tennis or pool. This was planned in order to stimulate patient B to be out of his room and at the same time to stimulate his appetite. An activities coordinator was allocated to the patient with the support of the nursing associate trainee (NAT) to support him with these activities. Personal care was agreed with the patient as well, this has a double purpose, firstly to enhance his physical health and secondly to improve patient B’s confidence.
The implementation stage follows on the planning, setting and directing of care. The nurse associate excels at this stage by following and implementing the care plan in the supplying of high-quality, safe and effective nursing care. This care has to be given in a personal and holistic way (Ian 2019).
Patient B was given information about his treatment options in order to elaborate an informed choice about his care. A cost benefit analysis tool was also used and completed by the patient and nurse team. the cost benefit analysis compares the pros and cons of following a specific treatment and how it would help the patient in the long term.
In the commencement of the ECT treatment, the care team found that Patient B had become very tiered and rigid impacting negatively in patient’s mood. However, the medical team implemented a medication review and looked at timings of prescribed medications. This intervention in Patient B’s drug chart has a positive impact in his treatment, making him more active and in a better mood. With this solved Patient B started his recovery faster than the care team predicted, he started to have better appetite with the result to gain more weight. Patient B’s care plan were subsequently drawn up and modified depending of the necessities.
Patient B with the assistance of the NA was educated about nutrition and the importance for his physical and mental health. To reassure his confidence and dignity, Patient B agreed to fill and record by himself daily food and fluid charts keeping copies of all with the purpose to check his progress and elaborate a list of SMART goals with the medical team. One of them was to increase his calorie intake daily by eating and drinking accorded amounts throughout the day.
The valuation stage is the last part of the nursing process. Once the care plan has been implemented, it is essential that the intended outcomes of it are assessed to find out if the goal have been achieved. The nursing team and the patient should be involved in the revision of this phase (Ian 2019).
In this stage, the nursing team evaluated the care given to Patient B with the aim to identify areas that could be improved. The main identified point was about the information that Patient B should have received regarding the medicines that he has been taken including the side effect of them. However, during this evaluation process this point was amended, providing patient B with leaflets and relevant and accurate information.
In conclusion, nursing models aim to guide nurses and NATs to offer the best intervention for patients. Nurses and NATs are encouraged to tailor made care plans, sett SMART goals and involve patients in creating strategies to helps increasing the speed of their recovery. In the study case above, patient B was able to take responsibilities over his own care and helped nurses to design his care plan. The regular review of all these helped nursing team to identify what was helpful for patient B and what needed to be amended. Initial and ongoing assessment of a patient are the basis on which nursing care is delivered. This assessment initiates the nursing process.
Nursing assessment tools help identify, and measure patient’s needs and risks. The RLT activities of daily living model helped the team to consider other fields that had been affected, with the opportunity to prioritise the care being provided. The assessment tool allowed the nursing team to identify the areas of patient B’s care to be reinforced and improved such as good diet intake, appropriate self-care and promotion of good physical health and activities. Patients should be at the centre of care and nurses and NATs must enable them to choose their treatment and make decisions about it. The holistic approach ensures a high level of care specifically created for patient B’s highlighting his needs and helping to treat his depressive disorder.