Postpartum Depression Concept map by

SBAR

brmpham — 2024-03-31 03:08:36 UTC

S: The patient is a 32-year-old married female. The patient presented alone to the ER. She reports feeling overwhelmed, sad, and has difficulty looking at, or touching the baby. She reports having difficulty sleeping and a loss of appetite.

B: She gave birth 2 months ago to her first child. She has a history of dysthymia that has been previously treated with a combination of medication and therapy. She states that she has not seen her psychiatrist or psychologist in over a year and is not currently taking any prescription medications.

A: Her current vital signs are BP: 110/60 mmHg, HR 94 bpm, respiratory rate 20 breaths/minute, temperature 37.5 °C (99.5°F), and oxygen saturation 99% on room air. She avoided answering questions of self-harm or other-directed violence. She expressed concerns about her ability to be a good mother and stated “why did I go ahead with this pregnancy?” The baby is notably facing away from the mother in a car carrier in the exam room.

R: I recommend the patient have a mental health consult and be provided support group resources for new mothers who may be experiencing the same thoughts or feelings. I will inform patient that they can receive free 24/7 confidential support andplease contact 1-833-TLC-MAMA. If the patient is having a crisis then please contact 988 for confidential and free support.

Complication 1

brmpham — 2024-03-31 03:09:42 UTC

Risk for self-harm or harming the baby as evidenced by avoidance of related questions, reported feelings of sadness, difficulty connecting with the baby, changes in sleep and eating pattern, and feeling extremely overwhelmed.

Complication 2

brmpham — 2024-03-31 03:11:16 UTC

Impaired self care as evidenced by difficulty sleeping, decreased eating, and not prioritizing her mental wellbeing.

Complicaion 3

brmpham — 2024-03-31 03:11:46 UTC

Impaired self esteem/self confidence in her new role as evidenced by feelings of difficulty connecting with the baby, facing the baby away from her, expressing feelings of concern about her ability to be a good mother, and stating “why did I go ahead with this pregnancy?”

Nursing Intervention 1

brmpham — 2024-03-31 03:17:14 UTC

Implement suicide risk assessment and safety plan. Conduct a thorough assessment of the patient's current mental health status, including the severity of depressive symptoms, presence of suicidal ideation, and potential risk factors for self-harm or harm to the baby.

Nursing Intervention 2

brmpham — 2024-03-31 03:19:09 UTC

Implement a structured self-care plan. Collaborate with the patient to identify specific self-care activities that align with their preferences and abilities. Break down self-care tasks into manageable steps, providing guidance and encouragement as needed.

Nursing Intervention 3

brmpham — 2024-03-31 03:20:24 UTC

Provide emotional support by establishing a trusting and empathetic therapeutic relationship with the patient, creating a safe space for her to express her feelings and concerns without judgment. Offer active listening and validation of the patient's experiences, acknowledging the challenges she is facing and validating her emotions.

Anticipatory Order

hamayren — 2024-03-31 19:02:31 UTC

The doctor will refer the patient to a psychiatrist to examine the patient as well as order psychosocial therapies and medications for the safety of mom and baby.

Nursing Actions

hamayren — 2024-03-31 19:08:30 UTC

Assign the patient a social worker to organize and carry out the following:

Conduct an interview with the patient to gain understanding and insight of the patient's mental status, behavior, and mood.
Coordinate with the patient's healthcare providers including psychiatrist to review the patient's physical and mental health status and organize a thorough treatment plan. (Including: financial support, support groups, accommodation and transportation)
Present plan of care to the patient and get consent to move forward and reevaluate as it progresses with the help of social services.