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case study

Name: Mr. Victor Chavez

Gender: Male

Age: 69

Ethnicity: Hispanic

Education: High School Diploma

Income: Social security, retirement, and Medicare

Religious/Spirituality: Practicing Catholic

Family: Widowed but is close to his remaining family

Diagnosis: Major Depressive Disorder (MDD) single episode

Chief Complaint

I am tired and dont want to go on anymore.

History of Present Illness

According to pt. daughters, pt. stopped caring for self approximately one week ago. Pt. wife died 6 months ago and he has not been the same since. Pt. is actively suicidal but has no plan. Depressed and withdrawn mood has affected pt. ability to care for self and feed self. Pt. states has no energy to do anything. Pt. states that nothing makes him feel better and that this feeling is constant.

Past Psychiatric History

No previous psychiatric treatment or hospitalizations. No previous psychiatric medications. No known past suicide attempts or self-harm.

Substance Abuse History

The patient denies a history of tobacco, alcohol or recreational drug use. Pt. daughters confirm.

Family History

Pt. parents deceased over 15 years ago. Both died from natural causes. Has 2 living brothers (ages 65 and 72) and 2 living sisters (ages 63 and 78). His 63-year-old sister has previous suicidal attempts and hospitalizations in psychiatric hospitals for major depressive disorder. No other mental health or substance abuse history in the family.

Social History

Pt. born and raised in Mexico. He immigrated to the U.S. after he graduated high school. Uneventful and stable childhood. Married his wife at the age of 21 and she died when pt. was 68 years of age. Pt. has 2 daughters, 2 sons, and 8 grand-children. He worked in the casino industry his entire life. Retired at the age of 65 and is now collecting social security and retirement. No financial concerns. Pt. is practicing Catholic with a strong faith in a higher power.

Mental Status Exam on Admission

The patient presented to the hospital accompanied by his two daughters. Daughters report the patient has not showered in the last week and is not eating or sleeping regularly. The patient is a 69-year-old English speaking Hispanic male; he is alert and oriented to time, place, person, and situation. Wearing unkempt clothing, hair is not clean or combed, and he exhibits overall poor hygiene. Pt. calm, cooperative and exhibits no unusual behavior. His speech is soft and slow. Depressed affect noted. Upon questioning his mood, the patient stated he felt sad and as though he did not want to continue living. Active suicidal ideations but no plan. The patients daughters state he has access to weapons in the home. No prior suicide attempts. Denies homicidal ideations. Denies being violent. Thought processes are linear. Pt. denies hallucinations or delusions. Short term and long-term memory intact. Pt can recall recent and remote events. Good insight/judgment; the patient states he knows that he needs help/ would mail a letter if he found one on the ground.

Past Medical History

Hypertension onset in mid-50s

Appendectomy as a child in Mexico

Medications

Lasix 40 mg PO BID

Lisinopril 20 mg PO Daily

Allergies

NKA

For this case study, answer the following questions. This assignment does not require APA formatting but does require scholarly writing. Please see the rubric for additional details.

  1. What information is pertinent to you as the nurse?
  2. What do you think the problem is?
  3. Prepare a list of goals for the client interview
  4. How will you introduce yourself to the client?
  5. What questions, based on your goals, will you ask the client?

Rubric

Case Study – Nurse Patient Relationship

Case Study – Nurse Patient Relationship
Criteria Ratings Pts

This criterion is linked to a Learning OutcomeContent

15 ptsLevel 4The content reveals pertinent and thoughtful information. It expertly covers all areas and major points.14 ptsLevel 3The content discusses pertinent information and includes thoughtful information. Most of the areas are included in the content but may be missing some information or detail.

13 ptsLevel 2The content discusses some information and includes basic content. Some major points may be missing in the content or not included wholly.12 ptsLevel 1The content is lacking significant detail or information. Many (3+) key points are absent or not discussed.0 ptsLevel 0The content is significantly incomplete or lacks any critical thinking and depth.

15 pts

This criterion is linked to a Learning OutcomeCritical Thinking

10 ptsLevel 4Strong evidence of critical thinking is demonstrated. Thoughtful and complete responses are added that directly address all aspects of the topic.9 ptsLevel 3Evidence of critical thinking is demonstrated with thoughtful responses. Some considerations or connections might be missing specific details or information.

8 ptsLevel 2Critical thinking is loosely identified or not properly connected. Details and relation between thoughts are lacking.7 ptsLevel 1Critical thinking is difficult to identify or is severly lacking. Basic thoughts and consideration are demonstrated but do not show means of connections.0 ptsLevel 0No critical thinking is identified. Significant detail and considerations to connect point and come to conclusions is not seen.

10 pts

This criterion is linked to a Learning OutcomeAcademic Language

5 ptsLevel 4Excellent use and control of language. Superior use of style and variety provided in a professional tone.4.5 ptsLevel 3Good use and control of language. Minor (<2) errors with use of style with some variety provided. Professional tone maintained throughout.

4 ptsLevel 2Average use and control of language. Some (3-5) errors or misuse of style with minimal variety. Professional tone maintained throughout.3.5 ptsLevel 1Below average use and control of language. Significant (>5) errors or misuses of style with no variety. Professional tone not maintained throughout assignment.0 ptsLevel 0Significant issues with use and control of language. Style and variety unable to be determined with no professional tone.

5 pts

This criterion is linked to a Learning OutcomeFormatting

5 ptsLevel 4Formatting follows assignment directions (APA if required) used with no errors. Citations provided (if necessary) with no errors.4.5 ptsLevel 3Formatting follows assignment directions (APA if required) with minimal (<2) errors. Citations provided (if necessary) with minimal (<2) errors.

4 ptsLevel 2Formatting mostly follows assignment directions (APA if required) with some (3-5) errors. Citations (if necessary) provided with some (3-5) errors.3.5 ptsLevel 1Formatting (APA if required) errors (>5) make following the assignment difficult. Citations (if necessary) mostly provided with significant (>5) errors.0 ptsLevel 0Formatting does not follow assignment directions. Significant errors make formatting illegible. Citations (if necessary) do not follow APA format.

5 pts

This criterion is linked to a Learning OutcomeScholarly/Professional Composition

5 ptsLevel 4Expert level of writing with little to no errors.4.5 ptsLevel 3Good level of writing with minimal (<2) errors.

4 ptsLevel 2Average level of writing with some (3-5) errors.3.5 ptsLevel 1Below average level of writing with significant (>5) errors.0 ptsLevel 0Level of writing is far below what is expected for scholarly/professional composition.

5 pts

Total Points: 40

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