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- QUESTION
Today you are meeting with Jane Sullivan, a 32-year-old newly widowed woman who is four months pregnant. Jane was referred to you by her nurse midwife, who has been caring for Jane for the last two months.
Jane enters your office looking exhausted. Her 18-month-old son, James, has food on his face and in his hair. Jane’s shirt is ill-fitting and crumpled, her hair is pulled back with just a rubber band, and her jeans have food crusted on them. It goes beyond the typical “mother of a toddler” look.
She starts to cry as soon as she sits down in your office and then has a hard time composing herself. She runs her hand through her hair, seeming to not notice the rubber band falling out. You try to distract James with a toy, but he clings to Jane and buries his face in her legs.
When she finally stops crying, she tells you, “I’m so sorry. I am having such a hard time dealing with everything. My husband, Jacob, was killed in Afghanistan last month by a roadside bomb. I’d only found out I was pregnant a couple weeks before that and Jake didn’t even know yet…. I…I must have gotten pregnant the night before he deployed. He’d only been gone for just three months.”
Jane takes a deep, shuddering breath and continues. “I’ve been having nightmares and barely eating.” She laughs and brushes at her jeans. “That’s from James’ lunch.”
James, who hasn’t left her legs, starts crying. While attempting to comfort him, she says, “We live on base. I don’t think I can stay there much longer and I don't know where to go. I don't have the energy to find a new home and pack and I just can't face it. Sometimes I think it would just be easier to pack the car with a few things and drive off when they tell me to leave.
"I just don’t know what to do with myself. I just wanna be with Jake. I don’t want to be with anyone else. Mari keeps asking me to come over, just for coffee, but I dunno, I never go.” Quietly, almost whispering, she says, “Actually, I’ve barely left the house except to see the midwife and now you. I have to protect the baby, since that’s all we’ve got left of Jake.”
James raises his tear-stained face. “Mommy? Where Dada?”
Jane digs in her purse and pulls out a crumpled piece of paper. “Hush, James. Here’s Daddy’s picture.” She wipes his face with a tissue and takes a few shuddering breaths.
“Back at the end of high school. You know how senior year is supposed to be the best year? Not for me. My daddy died. He was only 42, and I’d just turned 18. Supposed to be an adult and all I wanted was my daddy back. But at least I got to know him for 18 years. James and the baby won’t know their daddy at all!”
“I had to see a counselor for a while back then, too. I missed a lot of school, but I graduated anyway. My teachers all understood that I was depressed. I kind of feel the same way now. Only I think it’s way worse, being pregnant and having a toddler.” She half laughs. “And I thought senior year was bad. What a child I was!”
“And my Mom isn’t here to help. She died just before James was born. Breast cancer. Two years ago. I can’t even think about whether that might happen to me. I do have a sister, Bonnie lives out in Oregon. We were close before, but actually became even closer after Mom died. She was a big help giving me advice about James! But she’s going through a divorce and beginning life as a single mom herself! My nieces are 8, 7, and 5. Can you believe it? This whole family has lost parent after parent after parent.”
Jane sighs deeply and goes quiet.
Directions
Answer the following questions from your perspective as Jane’s psychiatric nurse practitioner, in a 1500-word (max 5 pages, not including the cover and reference pages) double-spaced paper, in APA format. Include at least five references, three of which must be scholarly articles on research or evidence-based practice.
- What diagnosis would you give Jane? Provide a rationale and evidence for your answer.
- What is your biggest concern for Jane? What should be addressed first?
- What pharmacological and non-pharmacological interventions would you suggest? Provide rationale and evidence to support your answer.
- Due to the gestation of Jane’s pregnancy, what issues might influence your decision-making process relative to pharmacological interventions? Provide rationale and evidence for your answer.
- Do you think James warrants any interventions? If so, what interventions would you make? What developmental tasks, according to Erickson, are these recommendations based on? Provide rationale and evidence to support your answer.
- What military and government resources might be available to Jane as a military wife? (Include links where possible.)
- In your community, what resources are available to young widows and widowers, as well as families of veterans killed in combat? (Dothan, Alabama)
All necessary criteria for full points are listed below…
- Diagnosis 0 pts
- Biggest concern 20.0 pts
- Pharmacological and non-pharmacological interventions 20.0 pts
- Pregnancy and pharmacological interventions 20.0 pts
- Intervention for James 20.0 pts
- Resources as a military wife 20.0 pts
- Community resources 20.0 pts
- References 10.0 pts
- Clearly listing each question before providing the answer 10.0 pts
- Writing, grammar, spelling, and APA format 20.0 pts
- Points: 180.0
| Subject | Nursing | Pages | 5 | Style | APA |
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Answer
Jane Sullivan Case Study
When people lose their loved ones and those close to them, it is only natural that they experience pain and grief. Notably, according to Hall (2014), grief refers to the natural response of death and loss of an important person or item. Although the grief process is normal, it can be detrimental if it takes over the life of the grieving person. In specific, when the grieving person begins to have feelings of hopelessness, helplessness, and worthlessness, then it is vital to make a difference between normal grief and prolonged grief (Boelen, & Smid, 2017). This paper provides a case study of Jane, a 32-year old who had had a series of losses as her father died when she was 18, and recently lost her husband and mother and later gave birth to James, an 18-month old son. The paper will discuss her diagnosis, biggest concern, and pharmacological and non-pharmacological interventions based on the case study. Additionally, resources that she can use to address her condition will be provided.
Diagnosis
I would diagnose Jane with a prolonged major depression arising from prolonged grief. Notably, depression is one of the mood disorders which affects the way that people feel, behave, and think. Some of the characteristics of depression include trouble undertaking activities of daily living and feelings of worthlessness (Boelen & Smid, 2017). Other symptoms include feelings of tearfulness, sadness, hopelessness, angry outbursts, and emptiness among others (Hall, 2014). In the case of Jane, depression is evidenced by the fact that she seems restless and cries regularly. Additionally, she feels hopeless and empty and experiences nightmares after the loss of her husband. Moreover, she lacks interest in interreacting with other people and only wants to see her midwife and the psychiatrist. Her depression arises from grief due to the loss of her father when she 18 and her mother and husband in the last two years.
Biggest Concern
The biggest concern in the case of Jane is the fact that she has not recovered from grief and does not want to see anyone else apart from the psychiatrist and her midwife nurse. In specific, without socializing with other people, she will not be able to let out her emotions and share her loss. Additionally, without interacting, she will not engage in support groups which can help her recover from the loss (Rosner et al., 2015). As such, it is important to address her isolation first not only for her own benefit but also for that of James, her 18-month-old son. Helping her share her story will dissipate not only the pain but also the grief. Sharing her tale will help her get support which will improve her depressive symptoms.
Pharmacological and Non-Pharmacological Interventions
The major depressive disorder from prolonged grief experienced by Jane can be addressed using pharmacological and non-pharmacological interventions. Medications which can be used include antidepressants such as serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), and tricyclic antidepressants (TCAs) (Granek, 2016). The specific medications in those categories are Celexa, Effexor, and Elavil among bothers. However, non-pharmacological interventions include cognitive behavioural therapy (CBT). CBT is psychotherapy which will help address the negative thoughts Jane has, restore her zest in life, and improve her self-esteem (Rosner et al., 2015).
Pregnancy and Pharmacological Interventions
Pregnancy results in many physiologic changes which can influence the absorption of drugs, their distribution, metabolism, and even excretion. For instance, an increase in gastric PH and a reduction in the motility of the intestine and increased cardiac output can influence the medications which are given to a mother within a specific gestation of pregnancy (Granek, 2016). In the case of Jane, the fact that she gave birth 18 months ago influences pharmacological interventions that I will provide. For instance, I cannot prescribe her lithium which may cause infant toxicity. I will need to ensure that the medications I prescribe do not have any adverse effects of her child in case she is breastfeeding.
Intervention for James
Just likely adults, children experience grief. However, the level of understanding of death for children depends on their age. In the current case, James will need to be told at the earliest time possible that his father is dead (Bryant et al., 2014). As such, he will need to be explained by her mother that he will not be able to unite with his father. Therapy will be vital for James whereby her mother will have to speak gently, frankly, and directly to him about his father’s demise. Although he may not understand parts of the explanation, it is vital that he knows about the death of his father. The intervention will be based on the second stage of Erickson’s developmental stage. In specific. Toddlers aged 1-3 years’ experience autonomy vs doubt/shame (Cherry, 2017). The toddler becomes able to explore the world and learn that they can control their actions. In this case, James; being an 18-month old, will be explained how he can control his emotions regarding the absence of his father.
Resources as A Military Wife
Various resources are available for Jane as a military wife. One of those is the Military One Source (https://www.militaryonesource.mil/) which provides comprehensive information on different aspects of military life such as grief and parenting. Additionally, the Flat Daddies (http://flatdaddies.com/) and Flat Mommies enable children to cope with separation especially when one or both parents are away. Moreover, military.com (https://www.military.com/spouse/military-life/military-resources/american-red-cross.html) is American red cross military resource which provides comfort and support to members who have lost their loved ones. Also, Create The Good (http://createthegood.org/toolkit/help-military-families) enable veterans to help those who have been left by their spouses to soldier on with life.
Community Resources
Various resources are available in the community which can help Jane recover from her grief and depression. One of those is GriefShare (https://www.griefshare.org/about) which serves widows and widowers in Dothan, Alabama county. This resource helps those who have loved ones to meet weekly and discuss challenges and even rebuild their lives. Through the video seminars with experts, support groups, discussions, and reflections, widows and widowers can recover from grief and go on with their lives. Additionally, Widowed Persons Service (http://www.widowedpersonsservice.com/) and Community Grief Support (http://www.communitygriefsupport.org/) are community resources which help widows and widowers in Dothan recover through sharing their experiences.
In conclusion, although grief is normal, it could affect the quality of life of an individual if it leads to mental health issues such as depression. In the case of Jane, she has a major depressive disorder based on the symptoms of tearfulness and feelings of worthlessness and hopelessness, among others. Pharmacological interventions for the condition would include antidepressants while non-pharmacological responses would be cognitive behavioural therapy. Additionally, her son; James, will need to be explained about the demise of her father and how to deal with it. Using military resources and community resources will help Jane recover move on from her loss.
References
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Boelen, P. A., & Smid, G. E. (2017). Disturbed grief: Prolonged grief disorder and persistent complex bereavement disorder. Bmj, 357, j2016. Bryant, R. A., Kenny, L., Joscelyne, A., Rawson, N., Maccallum, F., Cahill, C., ... & Nickerson, A. (2014). Treating prolonged grief disorder: A randomized clinical trial. JAMA psychiatry, 71(12), 1332-1339. Cherry, K. (2017). Erik Erikson's Stages of Psychosocial Development. Psychology. Psychosocial Theories. Päivitetty, 14, 2017. Granek, L. G. (2016). Medicalizing grief. Handbook of social justice in loss and grief: Exploring diversity, equity, and inclusion, 111-124. Hall, C. (2014). Bereavement theory: recent developments in our understanding of grief and bereavement. Bereavement Care, 33(1), 7-12. Rosner, R., Bartl, H., Pfoh, G., Kotoučová, M., & Hagl, M. (2015). Efficacy of an integrative CBT for prolonged grief disorder: a long-term follow-up. Journal of Affective Disorders, 183, 106-112.
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