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
“I am tired and don’t 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 Depressed and withdrawn mood has affected pt.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.
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.
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 patient’s 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-50’s
Appendectomy as a child in Mexico
Lasix 40 mg PO BID
Lisinopril 20 mg PO Daily
This assignment does require scholarly writing.
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?
Being a nurse requires an individual to be familiar with patients under their care. Several vital aspects about a patient aid nurses in identifying a patient without necessarily using their names only. As a nurse handling Mr. Victor Chavez, the following information is pertinent to me. First, the patient’s full names are essential to the nurse. In this case, Mr. Victor Chavez is the name of the patient.
Furthermore, the patient’s physical address and contact information are crucial. Under the address information, the street name, city, state, and ZIP code are noted. Contact information includes; home phone, work phones, and personal mobile phone numbers. The patient’s email address is also recorded as part of their personal information. The patient’s social security number and age are part of the required personal information relevant to a nurse charged with the care of a patient (Treas, Wilkinson, Barnett, and Smith, 2018).
Other additional information that may be relevant may include the name of the patient’s employer, the occupation of the patient, and the contact details of the employer. The physical address of the patient’s workplace also forms part of the relevant information to a nurse. In addition to these, the sex and marital status of the patient is similarly vital along with the individual to contact in case of an emergency. In this case, Mr. Chavez is a sixty-nine-year-old male who was recently widowed. He worked in a casino for the best part of his life and is currently collecting his social security benefits.
Based on the information obtained about the patient, including the medical history of the patient, the patient is going through a depression phase following the recent death of his spouse. This is probably the result of the patient being emotionally attached to the wife, and her current absence is causing the spike in depression levels. The pre-existing condition of hypertension only enhances the magnitude of this problem. These two medical conditions couple to form a significant depressive disorder. It is also likely that the current condition may have been caused by aggravated substance abuse at some period in Mr. Chavez’s life.
Relating to the interview with the patient, Mr. Chavez, the goals for the client to facilitate a recovery program include;
- Understanding the cause of the recent spike in Major Depressive Disorder (MDD).
- Establishing the most convenient rehabilitation and treatment plan for the client.
- Control the onset of hypertension on the client while managing the mental health of the patient.
- To develop a therapeutic relationship between the patient and the supportive physician.
- Build the patient’s confidence in the physician assigned to be handling him.
- Understand the patient’s condition comprehensively from the original course to the current pioneers.
- Establish all the relevant facts and join the missing pieces in coming up with a proper diagnosis for the patient.
As the nurse assigned to handle the patient, I will formally introduce myself using my official names while addressing the patient with his official name as displayed in the patient information from.
Based on the goals set, as the assigned nurse, I would ask the following questions to develop a comprehensive diagnosis of the patient’s condition. Establish how the patient is currently and compare it with how he was before the spouse’s death. Establish the patient’s underlying medical conditions from the symptoms experienced by the patient. Have a friendly conversation by inquiring about his sources of happiness from time to time. Finally, make inquisitions from the patient’s lifestyle to enhance the physician’s bond with the patient.
Townsend, M. C., & Morgan, K. I. (2019). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice( 10th ed.). Philadelphia, PA: F.A. Davis
Treas, L. S., Wilkinson, J. M., Barnett, K. L., & Smith, M. H. (2018).Basic Nursing: Thinking, Doing, and Caring(2nd ed.).