INTRODUCTION

I Mahima Eliazer student of M.Sc. Nursing 1st year. I was posted in psychiatric ward
in Teerthanker Mahaveer hospital and research center. I have selected a patient for my
case study and her name is Mrs. Shama. Her chief complaints are headache, chest
pain, dizziness and insomnia.

Identification data

Name Ms. Shama

Age 17years
Father Name Mohd. Kalib
Education 10th passed
Date of admission 06/12/2016
Occupation ----------
Marital status Unmarried
Religion Muslim
Socio-Economic Status Middle-class
Address Bangalore

Informants:-

Name : - Mohd. Kalib

Relation to patient: Father
Whether they stay with the patient or not: Staying with patient
Duration of stay together:- 17 years
Informants: The informant is Father and the information is reliable.

Presenting chief complaints

Patient said – Mjhe kisi se koi bat ni krni hai bas mjhko janey do yaha se.
Informant said: - Her father told that she is not talking to anyone and want to be
alone and some time she use to talk to herself, not taking food and not going
anywhere and do not like to meet anyone.
Onset of present illness: Insidious
 Duration of present illness: Last approx 3 months
Symptoms: Depressed Mood since 3 months
Talking to self since 2 months
Heaviness in Head since 3 months
Associated symptoms : Lack of Appetite since 3 months
Insomnia since 3 months
Headache since 3 months
Do not mingle to anyone since 3 months

History of present illness

As her father told that she is being in love relationship since 2 years with one
boy who live near her home. As all the family member of the girl thought they
met as a brother and sister so they do not interrupt before . But one day the
Elder brother of the patient saw them in the garden sitting together on
November 2016 .So from that day the elder brother start observing them very
keenly. So he observed that something other than brother-sister is going on, So
he told the parents about it and tell the patient that from now don’t meet him in
future and he also do not allow him to go out of the house. Sometime she tried
to meet the boy but again she has been caught by the family member and got a
scolding .Then after whenever she goes out some of the family member only
use to take her out. Slowly she start avoid to mingle with the family
member .She do not take proper amount of diet . And always have the complain
of insomnia, headache .Then after few days she start talking to herself assuming
that the boy is in front of her or with her. After that the family member thought
that the condition of the patient is getting worst So they decided to take her to
the psychiatrist and admit the patient in NIMHANS,Bangalore.

Life chart
HOSPITAL

Admitted on NIMHANS
D.O.A- 06/12/2016
Rx- Tb. Sarafem 1mg
Tb. Naxdom 500mg
 Past psychiatric and medical history

She do not have any psychiatric history like schizophrenia, mania and
depression and also no any past history like neurological, surgical, or any injury.

Treatment history

Sl. Trade name Dose Fre Action Action for client

No. and generic / q.
name rout
e

1 Tab. Sarafem 1 mg BD Treat My client is having

/ depressive depressed mood so this is
(Fluoxetine)
Oral mood given to her

2 Tab. Naxdom 500 BD Analgesic, She is having headache

mg / antipyretic
(NSAIDS)
Oral
Family history

Mohd. Kalib , Mrs.Shijana

Father, 54yrs Mother 49yrs

Mr.Sohil, Ms.Fiza Ms.Shama Mr.Sajid

21yrs, Job 19yrs, 17yrs 14yrs,Std

KEY WORDS

DEAD MALE

DEAD FEMALE

FEMALE CLIENT

FEMALE

MALE
SPECIAL

Personal history

Birth and oral development: She was a term vaginal delivered baby and do not
had any abnormalities.
Behavior during childhood: During childhood there were no complains like
sleep disturbances, temper tantrums, nail biting, bed wetting and stammering.
There were no conduct disturbances like stealing, lying, fights, relationships
with family members, siblings and parents were good.
Physical illness during childhood: There were no physical illness like
epilepsy, meningitis and encephalitis.
School: She started going school at the age of 4 years and finished at the age of
16, she went to girls schools, her performance at school was good and had good
attitude towards teachers and peer group.

Pre-morbid personality

Interpersonal relationship: - She had a good interpersonal relationship with

the family members and the neighbors.
Use of leisure time:- She like to do her household works and crafting.
Attitude to work and responsibility: - She is a responsible person in the
family and use to do all the household work in the home.
Religious beliefs and moral attitudes: - She is Muslim and has believe in God.

Habits :-
Food habits:- Non-Vegetarian
Alcohol:- No
Tobacco:-No
Drugs:-No
Sleep:- Normal
 MENTAL STATUS EXAMINATION
General appearance
Physique and body build:-Moderate body built
Physical appearance:-
Height:- 5’1
Weight:- 53kg
Appearance:- Good
Looks:- Uncomfortable
Level of grooming: - Normal
Hygiene:- Unhygienic
Dressing :-Normal
Attitude towards the examiner:- Non Co-operative
Comprehension:- Intact
Gait and posture:- Normal
Motor activity:- Lethargic
Social manner and non-verbal behavior:- Decreased
Eye contact :- Not maintained
Rapport:- Established
Hallucinatory behavior:- Auditory hallucination

Speech
Rate and quantity of speech
Speech:- Decreased
Initiation:- When required
Productivity:- Poor
Rate:- Low
I .Volume and tone of speech:-
Volume:- Decreased
Tone:- Low
II. Flow and rhythm of speech: Normal with lethargic state.

Mood and affect

Mood
Subjective: - Data on subjective mood are obtained by answers to question such
as
 Question: - How do you feel?
 Answer: - Acha ni lag rha hai mjhe yaha.
 Question: - What part of the day is most pleasant?
 Answer: - Koi bi samay mjhe yaha ni acha lgta, mjhe ghar jana hai
 Question: - What part of the day most difficult?
 Answer: - Jab mjhe nind ni aati yah ape.
 Question: - Do you become angry, depressed, irritable, frightened?
When? Why?
 Answer: - Jab jabardasti yeh log mjhe dawai khilatey hai aur yaha rukne
ko kahtey hai .

Objective: (by examination)

 Stability of mood (over a period of time):- Irritable and avoid people
around him.
 Reactivity of mood (variation in mood with stimuli):- depressed and
lethargic.
 Persistence of mood (length of time the mood lasts):- Till others force her
to do something like maintain personal hygiene , have food .
 Affect:-
 Affect was normal to the situation and to the emotion.
 Depth or intensity of affect :- normal
 Appropriateness of affect : (it was in relation to thought and surrounding
environment)

Inferences: mood and affect is congruent.

Thought: -

Stream and form of thought:

Initiation:-Delayed
Productivity:-Less than normal
Flight of ideas:- Not significant
 Word salad :- Not significant
Thought block:- Not significant

Content thought:

Any preoccupation: - no any idea was pre-occupied.

Obsessions/Compulsions:-By observing the patient I found that she is not
having any obsession and compulsion.

Contents of phobias:-

 Question: - Do feel afraid of being alone, fear of closed space or height, or any
kind of phobia.
 Answer: - No

Inference: - phobia and obsession is absent in my client.

Delusions

 Question: - Are you considered yourself friendly and popular?

 Answer: - No
 Question: - Do people like you? Treat you well?
 Answer: - No.
 Question: - Do they talk about you?
 Answer:- No
 Question: - Are you suspicious towards others like they are conspiring
against you?
 Answer: - No

Inference: - Delusions are not significant in my client.

Thought insertion / withdrawal / broadcasting

 Question: - Do you think others are able to influence you? How?

 Answer: - No, they can’t influence me.
 Question: - Do you think that some people can read minds? Can they
read yours? Control you? How?
 Answer: - no one can read, it’s not possible.

Inference: - thought insertion, withdrawal is absent.

Perception

Hallucination:- Absent
 Question: when you stay alone that time do you listen unknown voices or
seeing something different?
 Answer: - No

Illusion
 Question: - Do television gives you special message which it not known
to others?
 Answer: No it’s not like that.

Inference: Absence of hallucination and illusion.

Cognition ( neuropsychiatric) assessment

Consciousness

Level of consciousness: She is conscious

Patient is responding to voice:- Patient is responding

Inference: - Patient is fully conscious and provided the answer in normal voice.

Orientation:-

 Time: Question: - what is the time now according to you.

 Answer: - This must be near to 3 o’clock.
 Place: Question: - Do you know where you are now, and what is the
name of this city you know? And who I am?
 Answer: - She is aware of the present location hospital and also aware
about the city, and about student nurse.

Inference: - Client is fully oriented about the time, place and person.

Attention and concentration

 Question: If you have 20 chapatti in your house and 4 are eaten by your
elder daughter and 2 by your younger daughter, then how many are left.
 Answer: Able to reply
 Question: Can you name the week days
  Answer: - Able to name
Inference: Her attention and concentration is good.

Memory

Immediate retention and recall (IR and R)

 Question: - What is my Name ?
 Answer: - She is able to answer.

Recent memory:
 Question: - So what you had last night in dinner?
 Answer: - She replied

Remote memory
 Question: - What was your school name ?
 Answer: - She was able to answer.

Inference: - immediate recent memory and remote memory is good.

Intelligence:

 Question: - This season of which Crop?

 Answer: - She replied
 Question: - Which is the National Flower?
 Answer: - She Replied.

Similarities and differences

 Question: - What is the Similarity between Pen and Pencil?
 Answer: - both are used for writing.
 Question: - Difference between cooker and bowl?
 Answer – Cooker is used for cooking food and in bowl we keep the
bowl.

Inference: - intelligence of the client is good.

Insight

 Question: - Do you have any Illness, or why you came here?

  Answer: - yes, My family want that I don’t meet my friend. So that’s why they
have kept me here.
 Question:- What is the cause of illness
 Answer: - I am not sick.
 Question: - Do you want to free from this illness, want to be happy?
 Answer:-Yes I want to be free from here and be happy.
 Inference: - Patient is not aware about her illness.

Judgment

Social judgment

 Question: - If this whole ward getting burn and all clients sleeping what will
you do?
 Answer:- I will make the patients awake and tell them to run.

Personal judgment

 Question:- if you find letter in the road what will you do?
 Answer:- what I should do with that I simply go.

Inference :- Social and Personal Judgment of the client is good.

SUMMARY

Patient’s general appearance is unhygienic, and patient was non cooperative . The
speech was less productive. The findings of the interview shows that my client is
affected with depression as her all tests all normal, CT of the head were also normal.
No any significant findings she had so that we are not mis-interpreting it with any
physical problem.
 PHYSICAL EXAMINATION

GENERAL INFORMATION :-

Name Ms. Shama Date/Time – 06/12/2016

Age 17 years C R No.–--------
Gender Female Unit –Psychiatry ward

IDENTIFICATION MARKS:-

1. Mole on the neck

GENERAL PHYSICAL EXAMINATION

Pulse 76beats/min Pallor Absent

Bp Supine Icterus Absent
Temp. 98.8’F Cyanosis Absent
Respiratory Rate 24breath/min Clubbing Absent
Level Of Fully Lymphadenopathy Absent
Consciousness consciousness
Orientation Oriented Edema Absent
Pupils Fundus Absent
Height 5’1 Oral Examination:-
Weight 53kg Lips –
Tongue- .
Teeth –

SYSTEMIC EXAMINATION:-

Cardiovascular System
Heart Rate 76beats/min Heart Sounds Normal
Murmurs Absent
Other Positive Findings (If Any):-

Respiratory System
Air Entry Normal Adventitious Sounds Scratching sound
Breath Normal heard Grating sound
Sounds
Other Positive Findings (If Any):-

Per Abdomen
Inspection Normal Organomegaly Not significant
Palpation Not organomegaly
Other Positive Findings (If Any):-

MUSCULOSKELETAL SYSTEM:-

Body alignment- Body alignment is good.

Movement – Movements are normal
Joint – Joints are normal pain.

NERVOUS SYSTEM:-

Speech: Normal
Posture: Normal
Note: - posture is normal, verbal responses are normal. And she responded to stimuli.

Cranial Right Left Motor system

nerve
1 √ √ Right Left
2 √ √ Bulk √ √
3 √ √ Power √ √
4 √ √ Tone √ √
5 √ √ Reflexes
6 √ √ Right Left
7 √ √ Biceps √ √
8 √ √ Triceps √ √
9 √ √ Supinator √ √
10 √ √ Knee √ √
11 √ √ Ankle √ √
12 √ √ Corneal √ √
 Sensory Ri L Cerebellar Ri L
System gh e Signs gh e
t ft t ft
Pain √ √ Finger Nose √ √
Touch √ √ Dysdiadocho √ √
kinesia
Temper √ √ Tendem √ √
ature Walking
Pressure √ √ Rombergs √ √
Position √ √ Stereognosis √ √
DISEASE PROCESS
INTRODUCTION:-

Depression is a widespread mental health problem affecting many people. The lifetime
risk of depression in males is 8-12% and in females it is 20-26%. Depression occurs
twice as frequently in women as in men. Depression often is associated with a variety
of medical conditions.

DEFINITION:-

Depression is a common mental disorder , characterized by sadness , loss of interest or

pleasure, feeling of guilt or low self-worth, disturbed sleep or appetite, feeling of
tiredness and poor concentration.

Or in other words,

It is a state of low mood and aversion to activity that can affect a person’s thoughts,
behavior, feeling and sense of well-being.

ETIOLOGY

Depression occur due to many etiological factor like trauma, life events, due to
substance-induced and non psychiatric illness such as nutritional deficiencies ,
neurological conditions and psychological problems .
CLASSIFICATION ACCORDING TO ICD X

(F32-39) Mood ( affective ) disorders

(F32) Depressive episode

(F32.0) Mild depressive episode

(F32.1)Moderate depressive episode

(F32.2) Severe depressive episode without psychotic symptoms

(F32.3) Severe depressive episode with psychotic symptoms

(F32.8) Other depressive episodes- Atypical depression

(F32.9) Depressive episode , unspecified

(F33) Recurrent depressive disorder

SIGN AND SYMPTOMS: -

Common symptoms Other symptoms

1. Apathy 1. Fatigue
2. Sadness 2. Thought of death
3. Sleep disturbance 3. Decreased libido
4. Hopelessness 4. Dependency
5. Helplessness 5. Spontaneous crying
6. Worthlessness 6. Passiveness
7. Guilt
8. Anger
 DEPRESSION

Sign & Sx: Sign & Sx Sign & Sx:

Sign & Sx:
Inability to carry
Depressed Self – esteem
out activites of Helpleeness
mood disturbance
daily living and

Nsg Dx. Nsg Dx. Nsg Dx. Nsg Dx. Sensitivity

Dysfunctional Powerlessness and to criticism
High risk of lack of control
grieving
self directed
violence

Nursing actions:- Nursing actions :- Nursing actions: - Nursing actions: -

- Focus on strength
-Ask client about her -Assess stage of -Allow the client to take
and accomplishments
plan of harming her. fixation in grief decision regarding her
and minimize failure.
process own care.
-Create safe
-Encourage the client to Provide simple and
environment - Be accepting the
verbalize feeling about easily achievable
patient and spend time
- Close observation is areas that are not in her activity
required - Provide simple ability to control
Teach assertiveness
activities
and coping skill
Outcomes :- Outcomes :- Outcomes :- Outcomes :-
Client is now able to Client desire to participate
express his feeling and a Client is now able to in activity and accepting the Client is making the
proper safe environment accept the grieving issues which cannot be task complete with
is provided process and able to adjust changed positive attitude
 COMPARISON BOOK PICTURE AND PATIENT PICTURE

ETIOLOGY
BOOK PICTURE PATIENT PICTURE
1 Genetic predisposition X

2 Biological factors - Such as alterations X

in neurotransmitters, like level of
norepinephrine and serotonin
decreased

3 Particularly with feelings of √

hopelessness and/or helplessness

4 Chronic medical illness √

5 Ruminative coping strategies - These,

as opposed to problem solving or √
cognitive restructuring strategies.
DIAGNOSTIC CRITERIA
CLINICAL FEATURES
BOOK PICTURE PATIENT PICTURE
1 BOOK PICTURE
Physical examination PATIENT PICTURE
1 Apathy
Physical exam and ask in-depth questions Yes is not
Done- patient
2 about your health
Sadnessto determine what may be having any
Yesphysical
causing your dissociative. In some cases, it problem only
3 Sleep disturbance
may be linked to an childhood neglect and Yes disorder.
dissociative
4 childhood abuse..
Hopelessness Yes
5 Helplessness Yes
2 Lab tests
6 Lab tests areWorthlessness
done to rule out any physical No any Yes
positive
7 disorder, butGuilt
there wasn’t any physical disorder findings No
8 or any associating
Anger problem to physical illness. Yes
MEDICAL MANAGEMENT
3 Psychological evaluation.
BOOK PICTURE This includes AfterPATIENT
talk to patient
discussing your thoughts, feelings and behavior Patient having
PICTURE
1 and it may include
Antidepressant likeaSSRIs
questionnaire to help
,TCAs and MAOIs depressive√disorder
pinpoint a diagnosis. This evaluation can help
Benzodiazepines
determine whether you have depressive X
Anti-psychotics
disorder order or any physical problem. like X
2 shows
ECT significant finding but this client has not X
any significant problem. Patient is not having
Psychotherapy
psychological illness like anxiety disorder. X
 NURSING MANAGEMENT
Book picture Patient picture
1 Provide safe environment Provided
2 Provide for clients basic needs, Provided
promoting highest possible level of
independent functioning.
3 Provide best copying strategies to the Provided
client.

4 Support client/family participation in Provided

follow-up care/community treatment.

5 Provide information about condition, Provided

prognosis, and treatment needs.

CONCLUSION:-

Depression is a widespread mental health problem affecting many people. It is a

state of low mood and aversion to activity that can affect a person’s thoughts,
behavior, feeling and sense of well-being.
BIBLIOGRAPHY

o Townsend mary c; psychiatric mental health nursing concepts of care

in evidence-based practive; 7th edition; published by jaypee brothers;
page no. 609 to 615.

o R sreevani; a guide to mental health and psychiatric nursing; edition

4th; published by jaypee brothers; page no. 254 to 268.

o http://www.myoclinic.com, depressive.disorder.educ.exis.sem.

o http://www.study on incidence of depressive

disorder,pubmed,2010,17,September:56(5): 533-9
TEERTHANKER MAHAVEER UNIVERSITY, COLLEGE OF NURSING

CASE STUDY
ON
DEPRESSION

SUBMITTED TO: - SUBMITTED BY: -

Dr. NAGESHWAR MAHIMA ELIAZER
T.M.C.O.N M.SC 1ST YEAR
T.M.C.O.N