PSYCHIATRIC NURSING CASE STUDY
Major Depressive Disorder
HISTORY TAKING
1. Identification Data
Name: Mr. Ajay Raut
Age: 27 years
Sex: Male
Father's Name: Mr. Ramesh Raut
Address: 45, Shivaji Nagar, Pune
Education: [Link]
Occupation: Accountant, Private Company
Marital Status: Married (3 years)
Religion: Hindu
Informant: Patient's wife
Information: Relevant and reliable
2. Presenting Chief Complaints
The patient is admitted to the hospital with complaints of persistent low mood, loss of interest in daily activities, disturbed
sleep, decreased appetite, easy fatiguability, feelings of worthlessness and guilt, poor concentration, and social withdrawal
since the last 3 months.
3. History of Present Illness (HOPI)
Duration: Last 3 months
Mode of onset: Insidious
Course: Continuous, progressively worsening
Intensity: Progressive
Precipitating factor: Financial loss and work-related stress
4. Treatment History
Drugs: SSRIs — Fluoxetine 20 mg/day (started 3 weeks back, partial response)
ECT: None
Psychotherapy: None
Family Therapy: None
Rehabilitation: None
Family Tree
Father (55 yrs) — Mother (50 yrs)
|
Patient (27 yrs, married) — Wife (25 yrs) Sister (24 yrs)
Legend: □ = Male O = Female ▨ = Male patient
5. Past Psychiatric and Medical History
Number of previous hospitalizations (psychiatric): None — first episode
Complete or incomplete remission: Not applicable (first episode)
Duration of episode: 3 months (ongoing)
Treatment outcomes: Partial improvement on current SSRI
Detail of any precipitating factor: Financial/occupational stress
Surgical procedure / Accident: No
6. Family History
[Link] Name of Relation to Age
Sex Education Occupation Health Status
. Relative Patient (yrs)
1. Ramesh Raut Father 55 M 12th Pass Farmer Healthy
2. Sunita Raut Mother 50 F 7th Pass Housewife Healthy
Accountant (Pvt.
3. Ajay Raut Patient 27 M [Link] Unhealthy
Co.)
4. Priya Raut Wife 25 F 12th Pass Housewife Healthy
5. Sneha Raut Sister 24 F [Link]. Student Healthy
7. Personal History
i. Perinatal History
Antenatal Period: Uneventful
Intra-Natal Period: Uneventful
Birth: Full term, normal delivery
Birth Cry: Present
Birth Defect: No
Post Natal Complication: None
ii. Childhood History
Primary Care Given: Mother
Feeding: Breastfed
Age of Weaning: 6 months
Developmental Milestone: Age-appropriate, no delay
Behavioural and Emotional Problem: None significant
iii. Education History
Age of Beginning of Formal Education: 5 years
Academic Performance: Average to good
Extra Curricular Achievement: Participated in sports at school level
School Phobia: No
Reason for Termination of Study: Not applicable — completed [Link]
iv. Play History
Game Played: Cricket
Relation with Playmates: Good
v. Emotional Problem During Adolescence
No significant emotional or behavioural problem reported during adolescence.
vi. Puberty
Age of Appearance of Secondary Sexual Characteristics: 13 years
Anxiety Related to Puberty Change: No
vii. Obstetric History
Not applicable — male patient.
viii. Occupation History
Age Starting Job: 22 years
Current Job Satisfaction: Reduced since onset of illness; was satisfied earlier
ix. Sexual and Marital History
Type of Marriage: Arranged marriage
Duration of Marriage: 3 years
Interpersonal and Sexual Relationship: Was satisfactory earlier; reduced interest since illness onset
Extra Marital Relationship: None
x. Premorbid Personality
Interpersonal Relationship: Extrovert, friendly
Family and Social Relationship: Good, before illness onset
Use of Leisure Time: Reading, watching cricket
Pre-Morbid Mood: Even-tempered, cheerful
MENTAL STATUS EXAMINATION
1. General Appearance and Behavior
Appearance: Looks stated age, mildly unkempt
Facial Expression: Sad, blunted
Level of Grooming: Adequate but neglected compared to baseline
Level of Cleanliness: Adequate
Level of Consciousness: Conscious
Mode of Entry: Came willingly, accompanied by wife
Behavior: Withdrawn, cooperative
Co-operation: Cooperative
Eye to Eye Contact: Poor, avoids sustained contact
Psychomotor Activity: Decreased (psychomotor retardation)
Other Movement: None
Conversion and Dissociative: None
Hallucinatory Behavior: None observed
2. Speech
Initiation: Speaks only when spoken to
Reaction Time: Delayed
Productivity of Speech: Reduced
Volume: Low
Tone: Monotonous, low pitch
Relevance: Relevant
Stream of Speech: Slowed
Sample of Speech:
Q. How was your day today? A. I don't feel like doing anything. Everything feels heavy.
3. Mood and Affect
Objective Mood: Sad, tearful at times
Subjective Mood:
Q. What is your mood just now? A. I feel empty and hopeless, like nothing will get better.
Pre Dominant Mood: Depressed
4. Thought
Stream of Thought: Retarded (slowed thinking)
Form of Thoughts: No formal thought disorder
Content of Thought:
Delusion: No delusions elicited
Q. What thoughts come to your mind about yourself? A. I feel I am a burden on my family and I have failed them.
Q. Have you ever felt life is not worth living? A. Sometimes I feel it would be easier if I was not there, but I would not
act on it.
Obsessive Compulsive Phenomena: Absent
Phobia: No
5. Perception
Illusion: No
Hallucination: No hallucination elicited on assessment
6. Cognitive Function
Consciousness: Conscious
Orientation:
Q. What day is today? A. Correctly identified (Wednesday)
Q. What place/city is this? A. Correctly identified
Q. Who is with you? A. My wife
Attention:
Q. Count 1, 2, 5, 7, 10, 15 backward. A. Able to complete with some effort and prompting
Concentration:
Q. Spell 'WORLD' backward / subtract serial 7s from 100. A. Partially able, slowed and effortful
Memory:
Immediate Memory: Intact — able to register and repeat digits
Recent Memory: Intact — recalled breakfast correctly
Remote Memory: Intact — recalled date of marriage correctly
Judgment
Personal Judgment:
Q. What are your future plans? A. I don't know, everything feels uncertain right now.
Social Judgment:
Q. What would you do if a person near you collapsed? A. I would call for help.
Test Judgment:
Q. What would you do if you saw a house on fire? A. I would call the fire brigade.
Intelligence
Q. What is the capital of India? A. New Delhi (correct)
Abstraction
Q. What do people mean when they say 'don't cry over spilled milk'? A. It means not to worry about something that has
already happened and cannot be changed.
7. Insight
Grade IV — Patient is aware that he is ill and that the illness is partly due to stress, but has limited insight into the need for
full treatment adherence.
Q. What do you think is the problem? A. I think I am under a lot of stress and it has affected my mind and body.
Q. How would you describe your role in this problem? A. I feel I should have handled my work pressure better.
NURSING DIAGNOSES
● Risk for suicide related to feelings of hopelessness and worthlessness as evidenced by passive death wishes.
● Disturbed sleep pattern related to depression as evidenced by early morning awakening and patient's report of poor
sleep.
● Imbalanced nutrition, less than body requirements, related to decreased appetite as evidenced by reduced food intake
and weight loss.
● Ineffective individual coping related to depressive illness as evidenced by social withdrawal and avoidance of
responsibilities.
● Low self-esteem related to feelings of worthlessness and perceived failure as evidenced by negative self-statements.
● Impaired social interaction related to withdrawal behavior as evidenced by avoiding family and friends.
Nursing Care Plan
Nursing Diagnosis 1: Risk for Suicide
Nursing
Assessment Goal Planning Implementation Evaluation
Diagnosis
- Suicide risk
- Assess suicidal assessment done on
Subjective Data: ideation and risk admission and each
Patient
Patient verbalizes, level. - Provide a shift. - Removed
Risk for suicide Patient will remained safe
"It would be easier if safe, hazard-free sharp objects and
related to feelings remain safe with no self-
I was not there." environment. - hazardous items
of hopelessness as and free from harm incidents
Objective Data: Ensure close from surroundings. -
evidenced by self-harm during the shift;
Nurse observes low observation/one-to- Provided continuous
passive death during risk
mood, hopeless one supervision. - observation. -
wishes. hospital stay. reassessment
expression, social Administer Administered
ongoing.
withdrawal. antidepressant as Fluoxetine 20
prescribed. mg/day as
prescribed.
Nursing Diagnosis 2: Disturbed Sleep Pattern
Nursing
Assessment Goal Planning Implementation Evaluation
Diagnosis
- Assessed sleep
- Assess current
pattern and duration.
sleep pattern and
Subjective Data: - Encouraged fixed
disturbances. -
Patient reports, "I Disturbed sleep bedtime routine and Sleep pattern
Patient will Promote sleep
wake up very early pattern related to limited daytime improved to
achieve hygiene measures. -
and cannot fall back depression as napping. - Reduced some extent;
improved, Provide calm, quiet
asleep." Objective evidenced by noise and light in the patient reports
restful sleep environment at
Data: Nurse early morning ward at night. - slightly longer
pattern. bedtime. -
observes dull, tired awakening. Administered sleep duration.
Administer
eyes and yawning. prescribed
medication as
medication at
prescribed.
bedtime.
MEDICAL MANAGEMENT
Pharmacological
Antidepressant (SSRI): Tab. Fluoxetine — 20 mg/day — Provided
Antianxiety: Tab. Clonazepam — 0.5 mg/day (if needed for agitation/anxiety) — Provided
Sleep aid (short term, if required): Tab. Zolpidem — 5 mg/day — Provided
DISCHARGE PLANNING / HEALTH EDUCATION
● Recommended lifestyle changes for the patient and family.
● Regular exercise.
● Eat healthy, regular meals.
● Maintain sleep hygiene.
● Avoid substance abuse.
● Practice stress management strategies (relaxation techniques, deep breathing).
● Educate family regarding the illness, importance of drug compliance, and warning signs of relapse or suicidal
ideation.
● Encourage regular follow-up at the psychiatric OPD.
● Involve family and spouse in providing emotional support.