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Mr. John Gray's depression and admission to the hospital

Question:

Discuss about the Venlafaxine in Treatment of Depression.

In this report, I will discuss provide an overview of a 28 year old male Mr. John Gray, explaining the reason for his admission in the hospital, his medical symptoms, nursing problems associated with his treatment, required nursing care and an evaluation of decision making factors that may help his recovery following Levett-Jones clinical reasoning cycle (Levett-Jones, 2013). In the final section I will contemplate my learning from the experience.

Mr. John Gray is 28 years old male and single who had been admitted to the ward a week ago following an episode of self harm. John belongs to the farming community, north of Brisbane and his father is a grazier. He expects to take over the family farm soon. He is facing several issues like bruise marks on his legs and arms due to failed suicide attempts. He does not take part in any activities management and is quite reluctant to socialize. Therefore, he has been admitted to treat his depression. Depression is a state of disordered mood and aversion to any form of activity that affects the health and well being of a person (Karp, 2016).

Mr. Gray’s farm appears to have suffered a great deal owing to the present drought conditions in his district. He has a rope burn mark on his neck. On evaluation it has been found that the mark is a result of breaking of a rope, which he presumably used to hang himself. He has several bruise and broken skin on his legs and arms. They have occurred due to subsequent fall after his attempt to hang. However, he did not suffer any serious physical injuries. The areas where his skin got broken were covered with a tape and some nonadherent dressing. The occupational therapist reported John was reluctant to take part in any individual activity or small group games. When I went to introduce myself, he was lying on the bed with the covers pulled up high. He did not want to engage in any conversation. When I addressed him, he began to grunt and turned away from me and faced the wall. On medical assessment it was found that he had a normal blood pressure of 125/75, respiratory rate of 18 breaths per minute and a body temperature of 36.3 ºC. Respiratory rate is the number of breath taken by a person per minute. The normal adult respiration rate is 12 to 20 breaths per minute. His pulse recording was 66 beats per minute.  A normal heart rate while sitting or relaxing should be between 60-100 beats per minute.

Assessment of Mr. Gray's physical and psychological symptoms

Depression is generally classified as a form of common mental disorders. It is characterized by loss of interest, sadness, low self-worth, guilt feelings, loss of appetite, tiredness and lack of concentration (Solomon, 2014). John exhibited similar kind of a behavior on his admission to the hospital. Studies suggest that any form of financial loss can act as a risk factor and make a person vulnerable to depressive disorder. In this case study, John’s farm has suffered huge financial loss due to drought. This financial stress eventually brought about a sense of worthlessness and a feeling of despair in him (Greenberg, 2017). Evidence suggests that depression is one of the major risk factors for suicide. Patients who experience a delusion of poverty have a five times higher likelihood to commit suicide compared to those without such delusions management . His financial condition is probably responsible for previous suicide attempts (Crowe & Butterworth, 2016). He had a loss of appetite. He reluctantly went for lunch on compulsion but ate almost nothing and soon returned to his bed (Sowislo & Orth, 2013). The proves that he is suffering from dysthymic disorder, which is characterized by poor self esteem, low energy, poor appetite and feeling of hopelessness.

John is on a medication of 75mg venlafaxine twice a day and not subjected to any other medication or psychotherapy. It has been established that monotherapy is not sufficient to reduce depressive symptoms. This is the first issue in his treatment (Vel'tishchev, 2015). He needs a higher dose of the drug in conjunction with other medicines. Another issue is his eating habit. I was informed that he had again skipped breakfast. Studies provide evidence on the relationship between potential changes in appetite and food preference and depression. John was compelled to go for lunch but did not have it. The idea of force feeding is controversial in such eating disorders. It makes a patient more aggressive and violent. The third issue found related to the case study was his repeated suicide attempts. Suicidal ideation arises from hopelessness and continuous frustration. Unrealistic expectations make several patients determined to end their life (Riumallo-Herl et al., 2014). The mark around his neck and the bruises on his body provide evidence that he has tried to inflict self harm upon himself. Moreover, when I went to his room to introduce myself and build a rapport, he had the covers pulled up high, grunted and turned away. A suicidal tendency can make him attempt such a self harm for another time while being isolated in his room and can create devastating consequences (Shah et al., 2014) Therefore, constant monitoring needs to be done to ensure his safety.

Nursing problems associated with Mr. Gray's treatment

I attempted to contemplate on a questioning technique to achieve a sound understanding of his problems. I asked myself questions like, “what was the problem”, “how severe is his mental illness” and “what can be done to provide relief”. A psychiatric nurse is expected to identify probable outcomes specific for individual patients.  The ultimate goal was to improve the status of his health. The outcomes should have been mutually and distinctly identified. I wanted to determine the efficiency of probable therapeutic interventions (Gunasekara et al., 2014). Clarification of goals is an essential step in the therapeutic procedure. Goals should be measured in behavioural terms. I wanted to realistically describe the changes I intended to accomplish within a time frame. I wanted to establish short term goals for his betterment. My short term goals were to ensure that John will come out of bed and participate in small group games and individual activities at the end of two weeks. I wanted to ensure that he does not encourage suicidal thoughts, the sense of wellbeing gets established and he starts eating properly (Choon et al., 2015).

This will involve an assessment of his family and medical history, the factors responsible for the condition and involving his family for a better care provision. Research studies state that a patient taking multiple classes of antidepressants are likely to have better prognosis. A combination of bupropion (75-400mg per day) with venlafaxin can be used as a first line treatment method (Laib et al., 2013). Gradual administration of a combination of these two drugs will synergistically act to reduce depressive symptoms and will increase social function. Psychotherapy and cognitive counseling will also prove effective (Karyotaki et al., 2016). A trial, which involved more than 400 people with depression, found that a combination of these therapies and medication successfully treated depressive disorder in patients. Cognitive counseling, assisting him with personal hygiene and self care, initiating gradual conversation, encouraging him to write down his feelings on suicide, educating him on depression, constant supervision on his eating and sleeping patterns and providing a detailed information on the need for medical compliance can help in promoting wellness.

The treatment plan should be customized for him based on thorough assessment of his symptoms and an analysis of the side effects and therapeutic benefits. Comprehensive primary healthcare services are needed to promote optimal mental health in patients. Providing emotional support would ensure his safety, reduce helplessness and increase his trust in the staff (Driessen et al., 2015). Furthermore, the use bupropion in conjunction with venlafaxine can lead to a sudden increase in blood pressure and extreme sweating. Thus, there should be a constant monitoring on his vital signs. Furthermore, a high dose of the two drugs may lower the seizure threshold in the patient and increase its occurrence (Furukawa et al., 2014). The dosage of the medicines should be immediately reduced if the patient exhibits such an episode of seizure.

Short-term goals for improving Mr. Gray's condition

After I reflected on the incident, I was able to build a rapport with John and attend to his needs. I understood that the financial stress and family responsibility made him afraid and distressed. He was unable to devise a way of covering the monetary loss and felt embarrassed on his failure. This led to development of suicidal tendencies. I also realized, on appropriate interventions like empathy and emotional support, his self-esteem was rebuilt. It became difficult when he did not respond. I further reflected that it is necessary to employ interpersonal skills and non verbal stimuli (Renner, Cuijpers & Huibers, 2014). Combination of the two drugs as learnt from evidence based practice significantly lowered his symptoms. I learnt that such patients need continual therapy and counseling based support to recover.

Conclusion

Depression is a mood of disturbance, which is characterized by grief and sadness occurring due to personal tragedy, monetary loss or lack of interest in some activities. Providing treatment to a depressed patient is a significant job for a registered mental healthcare nurse in practice.  This report analyzed and reflected on the techniques I used to assess John’s bio-psycho-social needs and the probable treatment goals that I intended to achieve. The report also elaborated on references I gained after extensive literature reading, to clarify evidence-based treatment management. In conclusion, on using the clinical reasoning cycle as a parameter to identify the mental health issues, I was able to establish a proper scope of practice and formulate safe care provisions for the patient.

References

Choon, M. W., Abu Talib, M., Yaacob, S. N., Awang, H., Tan, J. P., Hassan, S., & Ismail, Z. (2015). Negative automatic thoughts as a mediator of the relationship between depression and suicidal behaviour in an at?risk sample of Malaysian adolescents. Child and Adolescent Mental Health, 20(2), 89-93.

Crowe, L., & Butterworth, P. (2016). The role of financial hardship, mastery and social support in the association between employment status and depression: results from an Australian longitudinal cohort study. BMJ open, 6(5), e009834.

Driessen, E., Hegelmaier, L. M., Abbass, A. A., Barber, J. P., Dekker, J. J., Van, H. L., ... & Cuijpers, P. (2015). The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update. Clinical Psychology Review, 42, 1-15.

Furukawa, T. A., Ogawa, Y., Takeshima, N., Hayasaka, Y., Chen, P., Cipriani, A., & Barbui, C. (2014). Bupropion versus other antidepressive agents for depression. The Cochrane Library.

Greenberg, L. S. (2017). Emotion-focused therapy of depression. Person-Centered & Experiential Psychotherapies, 1-12.

Gunasekara, I., Pentland, T., Rodgers, T., & Patterson, S. (2014). What makes an excellent mental health nurse? A pragmatic inquiry initiated and conducted by people with lived experience of service use. International Journal of Mental Health Nursing, 23(2), 101-109.

Karp, D. A. (2016). Speaking of sadness: Depression, disconnection, and the meanings of illness. Oxford University Press.

Karyotaki, E., Smit, Y., Henningsen, K. H., Huibers, M. J. H., Robays, J., de Beurs, D., & Cuijpers, P. (2016). Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects. Journal of affective disorders, 194, 144-152.

Laib, K., Brünen, S., Pfeifer, P., Vincent, P., & Hiemke, C. (2013). 1023–Therapeutic drug-monitoring of bupropion for depression. European Psychiatry, 28, 1.

Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia.

Renner, F., Cuijpers, P., & Huibers, M. J. H. (2014). The effect of psychotherapy for depression on improvements in social functioning: a meta-analysis. Psychological medicine, 44(14), 2913-2926.

Riumallo-Herl, C., Basu, S., Stuckler, D., Courtin, E., & Avendano, M. (2014). Job loss, wealth and depression during the Great Recession in the USA and Europe. International journal of epidemiology, 43(5), 1508-1517.

Shah, R., Franks, P., Jerant, A., Feldman, M., Duberstein, P., y Garcia, E. F., ... & Kravitz, R. L. (2014). The effect of targeted and tailored patient depression engagement interventions on patient–physician discussion of suicidal thoughts: a randomized control trial. Journal of general internal medicine, 29(8), 1148-1154.

Solomon, A. (2014). The noonday demon: An atlas of depression. Simon and Schuster.

Sowislo, J. F., & Orth, U. (2013). Does low self-esteem predict depression and anxiety? A meta-analysis of longitudinal studies.

Vel'tishchev, D. Y. (2015). Efficacy of Venlafaxine (Velaxin) in the Treatment of Depression: Results of Recent Trials. Neuroscience and Behavioral Physiology, 45(5), 576.

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