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Background Information.

A female, single, 29 years old from East Malaysia was admitted to the rehab on 22nd November 2017, due to multiple drugs abuse and depression. She was diagnosed with Major Depressive Disorder with Anxious Distress with Cluster B personality with Co-Morbid Substance Use. Therefore, my focus for her as a nurse is to recover from drug addiction and controlled her anxiety and depression.

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Pathophysiology.

Drug abuse or substance use disorder is a serious public health problem that affects almost every community and family in some way. Drug abuse also plays a role in many major social problems, such as drugged driving, violence and stress. It was also lead to homelessness, crime and missed work or problems with keeping a job. (Abuse, 2017).

Different classes of drugs have different tell-tale signs that signify usage. It depends on the drug of choice, and the symptoms may also vary. In this case, the client’s drug of choice were Methamphetamine and Amphetamine. Methamphetamine is a stimulant drug usually used as a while, bitter-tasting powder or pills, form looks like glass fragments or shiny, bluish-white rock. It is chemically similar to Amphetamine; a drug used to treat Attention Deficit Hyperactivity Disorder (ADHD) or sleep disorder. (NIDA, 2017). Whilst, Amphetamine is a synthetic stimulant-type medication that stimulates or excites the central nervous system and may results in a feeling of higher energy, focus, confidence and euphoria. (American Addiction Centers, n.d.)

Usually, people will get addicted to drugs because of a lot reasons such as; (1) peers pressure; especially teenager and young adults starts using it because they want to fit in. They wanted to be rebellious but they don’t understand the severity of addiction then. (2) depression; those having depression will prefers to self-medicate with abusive drugs and alcohols. (3) to feel good; they wanted to get rid the stress and anxiety and also wants to enhance their fun with using drugs so that they will feel better than they do. (4) availability of drugs; easy access to get the drugs especially in the night clubs. Or from peers; dealers and sellers. (5) broken family; parents divorce, physical and mental abuse also lead to addictions among teenagers and young adults. And (6) self-medicate; due to severe anxiety, stress, depression, trauma, undiagnosed mental illnesses, and loneliness are all reasons to be addicted by using drugs as medications to cope from what they feel and doesn’t want to do.

Sign and symptoms of drugs addiction may vary based on their drug of choice but there’s some common symptoms that we can detects and assess from the addicted person such as; (1) isolating from family and friends that not using drugs, (2) spending time with new friends to get high or drunks, (3) never having money or often asking to borrow money even for small items, (4) showing up late to works, schools or not showing up at all, (5) losing a job, (6) paying less attention to basic hygiene, (7) changes in sleeping patterns, (8) extremely private about possessions including their bag, room or car, (8) lying about using or drinking and (9) sneaking away to get high or drunk. Personality changes often occur with substance abuse and addiction.

Depression is a common and serious medical illness that negatively affects the feeling, the way we think and act. Lucky, it is also treatable. Depression causes feeling of sadness or loss interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work or at home. (Ranna Parekh, 2017).

Depression happen caused by a combination of genetic, biological, environmental and psychological factors such as; (1) personal or family history of depression, (2) major life changes, trauma or stress and (3) certain physical illnesses and medications, (4) abuse of recreational drugs.

Common sign and symptoms of depressions are; (1) persistent sad, anxious or empty mood, (2) feeling of hopelessness or pessimism, (3) irritability, feeling restless or having trouble sitting still, (4) feeling of guilt, worthlessness or helplessness, (5) loss of interest or pleasure in hobbies and activities, (6) decreased energy or fatigue, (7) moving or talking more slowly, (8) difficulty concentrating, remembering, making decisions, sleeping, early-morning awakening, oversleeping, (9) appetite and weight changes, and (10) thought of death or suicide, and suicide attempts.

According to (NIMH, 2016), not everyone with depression experiences every symptom. Some of them only experience a few symptoms and some are many. The severity and frequency of symptoms depends on the individual or their particular illness. Symptoms may also vary depending on the illnes stages.

History

I have referred her to see Psychiatrist for input regarding her history on the 23rd November 2017. According to the Psychiatrist who treated her; she was dealing, selling and using ecstasy started the age of 18’s. She been using it 2 or 3 times a day for 2 years. She was using it as a trend because everyone was using it and for income as well. She also had tried Ketamine also for around 2 years which is taking it 4 times a month. Last use more than 1 year from now. She also using Cannabis but taking it irregularly because she doesn’t like it. She consumed alcohol almost everyday in 2016 as she was working in a night club but stopped on December. Now her drug of choices are Methamphetamine and Amphetamine, last used 3 days before admission. Denies any DUI, alteration with law, accident or over dose. Stressors towards relationships with parents, sibling rivalry, labelled the problem child, useless better off not around and using her parent’s money. She also jealous with her sister, that was given whatever she wants and not her e.g.; study in London.

In 2009, her car was robbed and she was beaten up. Parents was upset and blamed her for the incident. In 2016, she lost 50K in money scam. Her intention is to surprise her parents with car, be independent and move out. She has 4 years abusive relationship. Since then, parents have taken away her finance, independence and etc.

She was a good student in the class with well academic results, active in extra curricular activities and was a prefect during middle school. She continues study in Bachelor of Business Administration in a famous local college in Malaysia.

Family history; father was working with lamps company as a Director and mother as a Human Resource for fashion company. Has younger sister doing law. Denies family history of psychotic illness. No surgical or past medical history. She never seen any Psychiatrist before, not on any prescription from Physician as well.

Nursing Physical Assessment.

Upon admission, vital signs were checked. BP: 121/78 mmHg, PR: 105/min, RR: 21/min, Temp: 36.8’C, Pain score; 0/10, SPO2: 99% on air, body weight: 55 kg, height: 160 cm.  Normal BMI. Denies weight and appetite loss. Good oral intake. Dressed neatly. Appears mild anxious, reporting she couldn’t sit still but she manage to do so and talkative. Dramatic in descriptions of story; keep blaming her parents and was tearful at time. Speak English which was spontaneous, coherent and relevant. Denies taking any drugs but requested to be urine tested for proof. Tremors at both hands can be felt. COWS scores; 8 (mild withdrawals). Having eczema over both hands and lower legs. Urine tests done; positive to Methamphetamine and THC, others all negative. Alcohol breathalyser negative. She was earlier sent to private hospital in Kota Kinabalu for assessment by RMO. She was prescribed with Tablet Diazepam 5mg ON for 3 days for insomnia. She claimed having severe insomnia for almost 1 year. Stable body gait. Overall, cooperative and orientated. 

Related Treatments.

She aware about her illness, explained by the Psychiatrist. She supposed to starts anti-depressant medication but she need to discuss and get consent from her parents. On her next review, which is on 27th November 2017, her parents give their consent to starts her with anti-depressant. She was prescribed with Tablet Seroquel IR 12.5 mg ON for sedation and Tablet Sertraline 12.5mg ON for 4 days then increase to 25mg ON for 1 week then after that 50mg ON until next review, and switched the Tablet Diazepam 5mg ON to Tablet Lorazepam 1mg PRN for panic attack.

Nursing Care Plan

My nursing care plan for this client are according to the ADPIE formula; which an excellent way to improve the critical thinking process and allows for the creation, evaluation and re-evaluation of procedures so that they can be implemented and modified until a desired outcome is achieved. (ADPIE – Nursing Process Steps, 2018).

As a nurse, I had planned my care for this client suffered with major depression. I should (1) determine the degree of impairment, (2) assess her coping ability, (3) assist her to deal with current situation, (5) provide for meeting psychological needs and (6) to promote health and wellness to her.

Nursing Diagnosis, Goals and Interventions.

1.     Impaired social interaction; insufficient or excessive quantity or ineffective quality of social exchange related to lack of support system.

My nursing focus are; (1) client will be able to identify feeling that lead to poor social interactions, (2) client will be able to interact with family and peers, (3) client will eventually voluntarily attend individual, group therapeutic meeting, (4) client will verbalize that she enjoys interacting with peers in activities and one-to-one interactions, and (5) client will state and demonstrate progress in the resumption of sustaining relationships with family and peers within 28 days.

Therefore, my nursing interventions are to; (1) provide minimal concentration activities such as drawing, because people with depression is lack of concentration and memory. So with such activities, that don’t have right or wrong, win or lose will minimize the opportunity to put herself down, (2) involve the client in gross motor activities such as cross fit because this activities will aid in relieving tensions and elevating the mood, (3) involve her in one-to-one activity when in a depressed level, so with that she can maximize the potential for interaction while minimize the anxiety level, (4) involve her in a group activities such as group discussion, music therapy and etc because when she socialize with peers, it will minimize the feeling of isolation, furthermore, genuine regard for others can increase the feeling of self-worth.

At the end of nursing interaction, she will participate in daily activities, shows eagerness to socialize with peers and express emotions productively. After 28 days, she can verbalize positive concept of self, know her strengths and limit as a human.

2.     Spiritual distress; impaired ability to experience and integrate meaning and purpose in life through connections with self, others and nature due to life changes.

Client obviously expressed intense feelings of guilt towards her parents, lack of hope, peace and acceptance as an evidence.

My nursing focus would be; (1) client will feel the connection with others to share thoughts, feelings and beliefs, (2) client will discuss with nurse two things that gave her life meaning in the past within 3 days, (3) client will keep a journal tracking thoughts and feelings for 28 days, and (4) client will state that she gained comfort from previous spiritual practices.

Therefore, the nursing interventions should be; (1) encourage her to write a journal to express her thoughts and daily reflection because it will help in identifying important personal issues and feeling surrounding spiritual issue. So, with it she will explore deeper of life’s meaning, (2) suggest a spiritual leader to contact the her because spiritual leaders are familiar in dealing spiritual distress and can offer comfort for her, (3) provide information on referrals, when needed for religious or spiritual information such as readings and community programs, because those tools are useful and she can also express other needs.

As an outcome, she will participate in the groups with others and having the courage to share her thoughts and feeling. Other than that, she able to discuss with nurse the two meanings of life and she was eager to knows more her life worth. Lastly, she wrote journals about feeling and thoughts within 28 days and stated that she appreciates her life so much and feels revived.

3.     Risk of self-directed violence; due to major depression, substance abuse and hopelessness.

Based on her history, she had previous attempts of violence towards her parents and suicidal plan a few times and suicidal attempts twice.

My nursing outcome are; (1) client will not inflict any harm to self or others, (2) client will demonstrate alternative ways of dealing with negative feelings and emotional stress, (3) client will demonstrate compliance with medications or treatment plan within the next one week, (4) client will start working on constructive plans for the future, (5) patient will state that she wants to live and (6) she will identify at least two or three person she can seek out for help and support as well as emotional guidance when she feels self-destructive before discharge.

As per my nursing interventions were; (1) identify the level of suicide precautions needed; either hospitalizations is required if high risk or if low risk is she safe going home with family members or friends supervisions because if the score is high, the client need to close supervision with safe environment, (2) contact the family, arrange for crisis counselling and activate links to self-help groups because the client need a network of resources to help diminish personal feelings of helplessness, worthlessness and isolation, (3) check for the availability of required supply of medications needed, normally Psychiatrist allowed to supply medications limited to 3 to 5 days, (4) encourage to express feelings such as sadness, anger and guilt and come up with alternative ways to handle feelings of frustration and anger because if she had the alternative ways she can learn how to deal with overwhelm emotions and gain a sense of self-control.

After one week, client was compliance to her medications regime. She also shows nurse the alternative ways to handle emotional stress and negative feelings. Other than that, she stated that she wanted to live her life and starting to do-list of constructive ideas for better future. After 28 days, she able to identify 2 or 3 persons that she can contact while on depression level with the help and supervision from family members.

Summary

As a conclusion, drug addiction is preventable disease. “Research has shown that prevention programs that involve the family, schools, communities, and the media are effective in reducing drug abuse” (Goldberg, 2016). Although many events and cultural factors affect drug abuse trends, when youths perceive drug abuse as harmful, they reduce their drug taking. It is necessary, therefore, to help youth and the general public to understand the risks of drug abuse for the teachers, parents and healthcare professionals to keep sending the message that drug addiction can be prevented if a person never abuses drugs. Prevention is the key.

There are a number of things people can do to help reduce the symptoms of depression. For many people, regular exercise helps create positive feeling and improve mood. Getting enough quality sleep on a regular basis, eating a healthy diet and avoiding alcohol can also help reduce symptoms of depression.

Depression is a real illness and help is available. With proper diagnosis and treatment, the vast majority of people with depression will overcome it. Nurses also helping with the excellence and brilliant nursing care to overcome depression from become more worsening, which harm the clients, families and society. 

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