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Pt. ACJ

62 year old female

Admitting Dx: Admitted to a psychiatric hospital with delirium, bizarre behavior, and agitation

Primary diagnosis: Persistant Depression Disorder

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Lamotrigine (Anticonvulsant) 12.5 mg q.O.D: Mood stabilizer, for low mood of depression.

SE: Headache, dizziness, blurred vision, and nausea/vomiting

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Ineffective coping and grieving related to her separation from her husband and life changes. The patient will work towards communicating how she will effectively manage this change, without suicidal ideations or further impairments from her persistent depressive disorder. 

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Ineffective coping and grieving related to her separation from her husband and life changes. The patient will work towards communicating how she will effectively manage this change, without suicidal ideations or further impairments from her persistent depressive disorder. 

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Interventions:

Identify community supports for separation from husband, allowing for socialization.

Communicate with the patient, how to effectively manage any judgments or criticism she may face in preparation for release into the world.

Speak of the things she does have: her dog, her sister, and her community (library, bible study groups, emotional regulation group.)

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Disturbed thought processes related to delirium and underlying mental illness.

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Disturbed thought processes related to delirium and underlying mental illness.

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Interventions

Conduct regular mental status assessments to monitor for changes in cognitive functioning and delirium symptoms.

Conduct a thorough assessment to identify potential underlying causes of delirium, such as medication side effects, metabolic disturbances, or infections.

Administer medications as prescribed to manage symptoms of delirium and stabilize mood.

Implement reality orientation techniques to help the patient maintain orientation to time, place, and person.

Implement environmental modifications to promote orientation and reduce sensory overload, such as maintaining a consistent daily routine and minimizing noise and distractions.

Goal of care; The patient's thought processes will become more organized and coherent, with a reduction in symptoms of delirium and improved overall mental health functioning.

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Risk for self-harm related to recent stressors and underlying anxiety and depression

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Risk for self-harm related to recent stressors and underlying anxiety and depression

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Interventions:

Conduct suicide risk assessment using a standardized tool.

Establish a therapeutic relationship to provide emotional support and reassurance.

Implement close observation protocols, considering 1:1 observation if necessary.

Remove any potential means of self-harm from the environment.

Collaborate with the treatment team to develop a safety plan.

Expected Goal of Care: The patient will remain safe and free from self-harm during her hospitalization.

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​​ACJ, a 62-year-old female, presents with delirium, bizarre behavior, and agitation, leading to admission to a psychiatric hospital. She has a current diagnosis of persistent depressive disorder and a history of alcohol abuse and gambling, which are in remission. Additionally, she has corneal dystrophy, glaucoma, and suffers from migraine headaches. Psychosocially, ACJ lives independently with her husband and dog, is supported by mental illness disability benefits, and has a strong support system consisting of her husband, sister, and physician. She attends emotional regulation groups weekly and enjoys reading and participating in bible study groups during her leisure time.

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The patient's diagnosis is a persistent depressing disease, which is the diagnosis of a long-term struggle with depression that is persistent, meaning it is always affecting her daily life. The patient has a history of alcohol abuse and gambling which are commonly used as distractions or coping mechanisms when suffering from a long-term mental illness such as this one. She is in remission which is a positive sign of her slow healing process. She has supports at home which help her, but she is on long-term disability due to this life-altering mental illness and recently has experienced a change in her life as she is separating from her husband. This disease is known to have life-long effects and cause those affected to lose interest in their daily activities, which is why it is impressive that this patient has hobbies, and enjoys being at the library.

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Topiramate (Anticonvulsant/mood stabilizer) 100 mg q.O.D: Mood stabilizer, sometimes used off-label for mood disorders such as mania-assisted depression and agitation.

SE: weight loss, abnormal vision, fatigue, impaired memory/concentration, sedation, anxiety, agitation, dizziness, speech problems.

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Trazodone 150mg qO.D: Antidepressant,

SE: insomnia, dry mouth, headache, hypotension, nightmares, slurred speech, weakness, tremors, drowsiness.

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Quetiapine 25-50 mg q.O.D: Antipsychotic, used for mood stabilization and depression.

SE: Sedation, weight gain, dizziness, metabolic changes (increased blood sugar, cholesterol), and extrapyramidal symptoms, seizure, cognitive impairment.

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Zolpidem (Ambien) 10mg b.i.d: Prescribed for insomnia/ sleep disturbance management, a side effect of  Trazodone (Antidepressant).

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Diclofenac 2.23% prn (topical) and Diclofenac enteric 50mg tab b.i.d (oral): Prescribed for pain relief, particularly for migraine headaches, which can be a side effect of Lamotrigine (mood stabilizer) or Trazodone (antidepressant). Additionally, it may address inflammation related to conditions like corneal dystrophy.

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Haloperidol 2.5-5mg IM/tab prn: Antipsychotic, for agitation and aggression, which are likely side effects or symptoms related to Persistent Depressive Disorder, and Topiramate.

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Lorazepam 1mg q4hrs: Prescribed for anxiety relief and agitation, which could be related to side effects of Topiramate (mood stabilizer) or the stress associated with housing uncertainty and impending separation from her husband.

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Nicotine patch 14mg q.o.d: Smoking cessation, addresses nicotine dependence.

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Despite her current presentation, during the mental health assessment, ACJ appears well-groomed, maintains appropriate eye contact, and exhibits clear and logical speech. She reports a "good" mood but experiences mild anxiety related to housing uncertainty and impending separation from her husband. ACJ is oriented to time, place, and person, with intact memory and insight into her diagnosis and treatment needs. However, she lacks insight into the reason for her admission and experiences mood fluctuations, becoming "sadder" at night.

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People with depression have physical changes in their brain. The chemistry in their brain via the neurotransmitters serotonin and dopamine play a role in depression and are naturally occurring neurotransmitters in the brain. Changes in function and communication between neurotransmitters and the interaction with neuro-circuits involved in maintaining mood stability affect depression. Hormones also play a part in depression, for example hormone changes due to menopause. Depression is more common in people who have relatives that are affected by depression.

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Depression is a mood disorder that causes persistent feelings of sadness and loss of interest. Depression affects how a person feels, thinks, and behaves. Depression can lead to a variety of emotional and physical problems such as, difficulties completing ADLs, unexplainable back pain or headaches, sedentary lifestyle, anhedonia, feelings of sadness or hopelessness, angry outbursts, loss of interests in most or all normal activities, such as hobbies or sports. Sleep disturbances are quite common either sleeping too much or insomnia. Reduced appetite and weight loss or increased cravings or food and weight gain are common. Feelings of worthlessness or guilt and fixating on past failures may increase suicidal thoughts or ideation. These symptoms are usually severe enough to interrupt day-to-day activities like work, school, social activities, and relationships with others.

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Jesulola, E., Micalos, P., & Baguley, I. J. (2018). Understanding the pathophysiology of depression: From monoamines to the neurogenesis hypothesis model - are we there yet? Behavioural Brain Research, 341, 79–90. https://doi.org/10.1016/j.bbr.2017.12.025

National Research Council (US) and Institute of Medicine (US) Committee on Depression, Parenting Practices, and the Healthy Development of Children; England MJ, Sim LJ, editors. Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention. Washington (DC): National Academies Press (US); 2009. 3, The Etiology of Depression. Available from: https://www.ncbi.nlm.nih.gov/books/NBK215119/

Saveanu, R. V., & Nemeroff, C. B. (2012). Etiology of depression: Genetic and environmental factors. Psychiatric Clinics of North America, 35(1), 51–71.https://doi.org/10.1016/j.psc.2011.12.001

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Mood instability and fluctuations related to depressive episodes

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Mood instability and fluctuations related to depressive episodes

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Interventions:

Monitor the patient's mood and affect regularly, especially during times of day when mood fluctuations are most pronounced.

Collaborate with the treatment team to adjust pharmacological interventions as needed, considering the potential impact of medications on mood stability.

Implement psychotherapeutic interventions, such as cognitive-behavioral therapy to enhance emotional regulation and coping skills.

Expected Goal of Care: The patient will demonstrate improved mood stability within two weeks, as evidenced by reduced frequency and intensity of mood swings, and increased ability to maintain a consistent positive mood state.

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Self care deficit related to anxiety, fatigue, and preoccupation of thoughts “becomes sadder in the evenings”.

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Self care deficit related to anxiety, fatigue, and preoccupation of thoughts “becomes sadder in the evenings”.

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Expected outcome: The patient will improve sleep habits and engage in self-care practices.

Interventions

Review and assess medication regimen and ensure the patient is compliant with administration. Trazodone, Haloperidol, and Lorazepam for anti-depression effects and anxiety. Zolpidem to assist with establishing regular sleep patterns.

Set a specific sleep/wake schedule and routine for eating, grooming, and dressing to ensure motivation.

Encourage patients to eat with others. This will ensure the patient is getting nutrition and will help increase socialization.

Monitor nutrition and hydration status. Provide nutritious snacks, meals, and fluids. Patients with depression may lack the appetite and energy to prepare meals and may be dehydrated.