1803NRS Foundations Of Professional Nursing Practice

Socio demographics – summarise the demographic information for the person – age, sex, marital status, number of children, financial status, transportation, who they live with, employment etc.

Presenting issues and provision diagnosis – describe the problem or symptoms that the person presents with. Describe any physical, emotional, or sensory symptoms reported by the person. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that have been conducted should be noted. A provisional diagnosis is indicated by placing the specifier “provisional” in parentheses next to the name of the diagnosis. For example, it might say something like 309.81 Posttraumatic Stress Disorder (provisional). Once more information is gathered and a final diagnosis is made, this specifier is removed (see the course site for more information). Try to link the presenting issues for the person to your provisional diagnosis. Make sure to use the DSM-V for your diagnosis (see the course site for the link to online DSM-V)

Janice is a 17 year old woman living in a remote Aboriginal community.  She is 20 weeks pregnant.  Her grandmother has brought her to the community health centre for a check up to make sure both she and the baby are okay as she has noticed that Janice has been acting a little strange lately.

Janice reported a prior history of petrol sniffing and drinking alcohol that started at 10 years of age.  Janice stated that she stopped using several years ago after experiencing hallucinations and paranoid thoughts. At this time, she was linked with an Indigenous youth mental health service but has not had any contact with mental health services for over 2 years and currently does not take any medication.  Janice reports that she sometimes hears voices from the spirit world but does not find these distressing. Janice reports that lately she has been having difficulty sleeping and is feeling ‘moody and angry most of the time’.

Socio demographics

The socio-demographic data as obtained from the given case study shows the following:

Name of the patient: Janice

Gender- Female

Age- 17 years

Current health status- 20 weeks pregnant

Origin- Aboriginal community

Past drug history- petrol sniffing and drinking alcohol from 10 years of age

Past medical history- Type 2 diabetes, psychological problems which needed mental health care.

Education- Left school at 14 years of age

Marital status- not married, lives with partner

Family income- Below average

Primary carer- Grandmother

Presenting issues and provision diagnosis 

The presenting issues for Janice includes being worried about her baby as there she and her partner are facing financial crisis, therefore she is worried that how will they take care of the baby financially. Janice also seems to be worried due to the increased number of suicides taking place in their community. She also got very emotional after her cousin had hanged himself almost 3 months ago. She also reported that her family has gone through lot of bad luck which makes her quite sad because of which sometimes it is even difficult for her to get out of bed. Most of times she stays aloof and the family can even recognise her on some occasions. The issues also stated that she has been previously treated by a psychologist and a traditional healer for mental health, however now she doesn’t want to see anyone regarding this issue. She showed symptoms like headaches, lack of concentration, continuous feeling of tiredness along with aches and pains.

The provision diagnosis in the case of Janice is Depression DSM-5. The diagnostic criteria for DSM-5 includes depressed mood along with loss of interest or pleasure which are evidently shown by Janice. She also shows a decrease in appetite as well as slowing down of thought and reduced physical movement according to the diagnostic criteria of DSM-5 (Stein et al., 2014). Often there are feelings of guilt along with worthlessness. She also finds it difficult to concentrate or think clearly almost every day.

Person Centred Care Plan for Depression   Goal/s:  To manage depression for the patient before the birth of the child so that it does not affect the pregnancy of the patient.
Strengths to draw upon: The strengths include support received from the partner and her grandmother. She now wants to improve in her studies so that she can learn to read books for her baby. Although she has been away from her family for a long times, she now wants to meet her mother and is anxious to see her again.	Barriers which interfere:   The barriers are the prevailing risks of depression like the high rates of suicides in the community. Additionally there are financial issues.
Interventions and action steps: Self-care is an important intervention that needs to be implemented like maintaining a diet or losing some weight because of the prevalence of type 2 diabetes (Thombs et al., 2014). Support from the primary carer is essential for the well-being of the patient. Implementation of psychotherapy is recommended as a first-line treatment. Taking of anti-depressants might also be recommended which needs to be decided by the physician (Talley, 2013).

 

Formulation matrix

The formulation matrix helps to provide individualised care to the individualised care to the individuals who required mental health care (Bragazzi & Del Puente, 2014). The matrix addresses the precipitating factors along with the perpetuating factors, predisposing factors and the protective factors that is related to the biological, psychological and the social factors of the patient (Jorge et al., 2015).

	Precipitating factors (immediate factors that have caused the presenting issue/s)	Predisposing factors (factors in the person’s history that makes them more susceptible to the presenting issue/s)	Perpetuating factors (factors that are causing the person’s presenting issue/s to continue or worsen)	Protective factors (factors that provide resilience and strength and help to mitigate the presenting issue/s)
Biological factors	Pregnancy	Past drug use as a child	Type 2 diabetes	Presence of the baby
Psychological factors	Guilt for death of cousin, feeling of lingering bad luck in the family	Brought up in foster homes	Death of the cousin who hanged himself	Support from partner and grandmother
Social factors	Distance from parents ,   Financial conditions , suicides in the community	Abused in the foster homes. No such relationship with the parents	Poor financial condition of the family	Proper self-care

References

Bragazzi, N. L., & Del Puente, G. (2014). A proposal for including nomophobia in the new DSM-V. Psychology research and behavior management, 7, 155.

Jorge, M. S. B., Diniz, A. M., Lima, L. L. D., & Penha, J. C. D. (2015). Matrix support, individual therapeutic project and prodution in mental health care. Texto & Contexto-Enfermagem, 24(1), 112-120.

Rai, D., Lee, B. K., Dalman, C., Golding, J., Lewis, G., & Magnusson, C. (2013). Parental depression, maternal antidepressant use during pregnancy, and risk of autism spectrum disorders: population based case-control study. Bmj, 346, f2059.

Stein, D. J., McLaughlin, K. A., Koenen, K. C., Atwoli, L., Friedman, M. J., Hill, E. D., … & Alonso, J. (2014). DSM?5 and ICD?11 definitions of posttraumatic stress disorder: Investigating “narrow” and “broad” approaches. Depression and anxiety, 31(6), 494-505.

Talley, L. (2013). Stress management in pregnancy. International Journal of Childbirth Education, 28(1).

Thombs, B. D., Arthurs, E., Coronado-Montoya, S., Roseman, M., Delisle, V. C., Leavens, A., … & Coyne, J. C. (2014). Depression screening and patient outcomes in pregnancy or postpartum: a systematic review. Journal of Psychosomatic Research, 76(6), 433-446.