To get started on your assessment task, please follow the instructions below;

1. Choose a population group and health issue to focus on (from the suggestions above)
2. Choose one Case Study. A case study is an intensive investigation about a single individual, group or community.
   1. Read the VU Library Case Study Guide
   2. Read the Example Case Studies opens in new window
   3. Book into a Library Workshop opens in new window for more support
3. Locate a minimum of 3-4 academic references that will help you discuss and analyse the themes and issues within the Case Study (e.g. a variety of peer-reviewed journal articles, textbook chapters, government reports)

Case Study Report structure:

• Overview (~300 words): Make clear the specific case study you have chosen for your research topic and discuss relevant health characteristics and risks for the disadvantaged population you have chosen, including environmental factors, social determinants, and barriers to healthcare.
• Context (~300 words): Discuss the health care priorities in the case study as presented.
• Role of the nurse (~300 words): Discuss the role of the nurse in providing care for this specific population group, in relation to communication, teams, and person-centred care within the community.
• Health promotion & education (~300 words): Propose health promotion and education strategies for this population group, and provide relevant services available for person(s) in your care, e.g. ‘People with disability’ – Services Australia opens in new window; ‘Who can assist?’ – Beyond Blue opens in new window
• Referencing: Academic references (e.g. peer-reviewed journal articles, textbook chapters, government reports) must be used to support your work. References must be current (dated within the last ten years). TIP: See the Academic Skills & Support opens in new window for more contacts and information about referencing.

Critical Thinking Case Studies

Tedra S. Smith, DNP, CRNP, PNP-PC

Adolescent Depression

Laura Steadman, Karen M. Coles, and Lisa W. Myers

Case Presentation

Justin is an 18-year-old African- American male presenting to the clin- ic per his mother’s persuasion. His mother reports that he has had fatigue, loss of energy, irritability, lack of motivation, decreased ability to concentrate, poor hygiene, low self- esteem, and weight loss. Justin refuses to interact with friends. His mother states: “He goes to school and then comes home and goes to bed or lays on the couch.” His mother says she has noticed a gradual decline in his hygiene and lack of motivation over the last six months. She also reports that his grades have dropped from A’s and B’s to B’s and C’s this quarter. His mother denies Justin having learning problems.

Past Medical History

Currently, Justin does not have a primary care provider. Justin denies any food, environmental, or drug allergies. He admits to smoking a half pack of cigarettes on weekends for the last year and marijuana on occasion or when “I can find someone selling

pot.” Justin also admits to drinking beer when at social activities. His mother states he is up to date on immunizations. Justin denies consti- pation, diarrhea, dry skin, or heart pal- pitations.

Development and Growth History

Justin exhibits normal growth and development (weight and height) for age and sex.

Family and Social History

Justin’s family medical history con- sists of diabetes, cancer, depression, and hypertension. Both of Justin’s grandfathers have a history of hyper- tension and diabetes. Justin’s father’s paternal uncle has a history of depres- sion. Justin’s grandmother has had breast cancer. Justin’s parents have been married for 20 years. He has two younger sisters who live in the home. In the past, Justin was involved in soc- cer and football; however, he does not express any interest in sports now. Justin states he had a “break up” with his girlfriend six months ago.

Nutritional History

Justin’s appetite has decreased over the last six months, and he has expe- rienced a 10-pound weight loss.

Physical Assessment Findings

General appearance: Justin comes to the clinic today at the urging of his mother due to her concerns for his mental health. He is awake, alert, and oriented to person, place, and time.

He is cooperative and appropriately responsive to questions.

Vital signs: Temp: 98.6, Height: 69.5 in, Weight: 57.1 kg (126 lbs), HR: 72, RR: 16, BP: 128/82. BMI: 18.3.

HEENT: Normocephalic, conjuncti- va clear, sclera clear bilaterally, EOMI, PERRLA, TM pearly gray with normal cone of light, no TM inflammation, no sinuses tenderness to palpation frontal, maxillary sinuses rhinitis, uvula mid- line, neck supple, no anterior cervical submental and submandibular tender- ness or lymphadenopathy, thyroid not palpable, trachea midline, and full range of motion of neck.

Integumentary: Skin warm and dry to touch without lesions and/or cuts. Multiple red papules, open and closed comedones present to face. No bruises, rashes, or scars; erythema; discol- oration; ecchymosis; or skin lesions noted.

Respiratory: Normal shape of chest with no obvious deformities. Respirations even and non-labored. Breath sounds clear bilaterally upon auscultation. No stridor, wheezes, crackles, or rubs. Good air movement.

Cardiovascular: RRR (regular, rate, and rhythm), without murmurs, rubs, or gallop, positive cap refill, 2+ pulses in all extremities noted.

Abdomen: Abdomen is soft, non- tender, and nondistended; no hernias, masses or lesions noted. Active bowel sounds in all four quadrants. No hepatosplenomegaly.

Neurological/psychiatric: Oriented to person, place, and time. Makes appropriate eye contact and conversa-

Laura Steadman, EdD, CRNP, RN, is an Assistant Professor, The University of Alabama at Birmingham, Birmingham, AL.

Karen M. Coles, DNP, RN, is an Assistant Professor, The University of Alabama at Birmingham, Birmingham, AL.

Lisa W. Myers, MSN, CRNP, RN, is the Owner, The Healthcare Clinic of Fort Collins, Fort Collins, CO.

Critical Thinking Case Studies is designed to test your problem-solving and decision-making abilities.
Instructions: Read the symptom(s) above. Then, outline how you would assess and manage the problem. Finally, compare your

rationale and decision to that listed in the shaded area.

If you are interested in author guidelines for this column or would like to submit material, contact:

tion. Speech and cranial nerves 1-X11 normal. Mood and affect are confluent and full range. Thought process is lin- ear and goal-directed. Denies suici- dal/homicidal ideation, auditory and/or visual hallucinations. Insight and judgment are good. Has poor grooming and hygiene. Is cooperative. Speech is spontaneous and normal.

Musculoskeletal: Full range of motion (ROM). 5/5 strength UE/LE bilaterally. No edema noted, ambulates with a steady gait, good ROM in all major joints, 5/5 strength against resistance. Normal, equal strong dorsi/plantar flexion.

Genitalia: Tanner Stage V noted. Extensive assessment not completed at this visit. Denies dysuria and/or urgency.

What Do You Suspect?

Justin is an 18-year-old male being seen for fatigue, loss of energy, irri- tability, lack of motivation, decreased ability to concentrate, poor hygiene, low self-esteem, and weight loss.

Differentials

Depression

Depression is a condition that includes disruptive mood disorders and major depression disorder, and is characterized by fatigue, sadness, and irritable mood, with impaired func- tioning (Lacuesta & Gladwell, 2018). Depression and anxiety also represent the second and fifth leading causes of years lived with a disability and losses in work productivity (Kroenke et al., 2016). Common systems are fatigue, weight loss or gain, loss of energy, diminished interest or pleasure, agita- tion, feeling of worthlessness, recur- rent thoughts of death or suicide, decreased ability to process thoughts, and lack of motivation.

Diagnostic tests are crucial for prompt interventions and improved outcomes. The Patient Health Ques- tionnaire Anxiety-Depression Scale (PHQ-ADS) and the Depression, Anxiety and Stress Scale (DASS) diag- nose anxiety and depression. Ac- cording to Thapar, Collishaw, Pine, and Thapar (2012), depression in ado- lescents is often missed more than in adults.

Suicide Ideation

Suicide refers to a self-inflicted, willful, life-threatening act that has

resulted in death (Berman, Silverman, & Bongar, 2000). According to the Centers for Disease Control and Prevention (CDC) (2018), suicide is a major public health concern that affected over 45,000 individuals in 2016 in the United States. Risk factors can include substance abuse, family history of suicide, physical illness, depression similar to an adult, and not feeling connected with friends and family (Shain, 2016). Identi- fication of suicidal behaviors is essen- tial. Active strategies to include gener- al screening programs, training in schools to help identify suicidal behaviors, and education about sui- cide, crisis centers, and hotlines num- bers are available for clients and fam- ilies (Shain, 2016).

Management Plan and Recommendations

Justin was diagnosed with depres- sion. Lab test ordered are Total and Free Testosterone, TSH, Vitamin D3, CBC, CMP, TSH Total T4, and Free T3. According to the National Institute of

Mental Health (2018), most people benefit from therapy or counseling to discuss thoughts, feelings, and issues regarding what is happening current- ly in life. Justin should return to clinic in two weeks to recheck, but if con- cerns of suicidality emerge, he is to return to clinic sooner. There should be a careful screening to identify any recent thoughts or actions about sui- cide. See Figure 1 for the full recom- mended treatment plan.

Conclusion

Justin will return to the clinic in two weeks to reevaluate the effective- ness of medication. Counseling will be arranged for Justin to allow him to talk about his thoughts and feelings. His mother will monitor nutritional intake to help improve his overall well-being. Encouraging daily exercise can reduce the risk of chronic disease and promote overall health. Justin and his mother were given the National Suicide Prevention Lifeline 1−800−273−TALK (8255),

Figure 1.
Recommended Treatment Plan for Adolescent Depression (Based on This Case Study)

The recommended plan includes: • Medication.

Discuss prescribing sertralinen antidepressant.

How to take the medication: May increase dose after one week to 100 mg if no improvements, may have GI upset initially with medication but needs

to keep taking and GI upset will resolve. Take medication at night to help

prevent GI upset.

Side effect of the medication: Do not drink alcohol with medication.

Underlying symptoms of depression or anxiety may worsen because

alcohol is a depressant that can have an affect on the brain. • Psychotherapies.

Cognitive behavioral therapy (CBT).

Dialectical behavioral therapy (DBT).

Stress management.

Frequency of encounters with the health care team to discuss feelings and

thoughts. If having hallucinations (visual/auditory), seek emergent care.

Peer support programs.

Crisis center hotline.

Physical activity.

Engage in 30 to 60 minutes of moderate exercise per day and/or use the

stairs at work, home, or school if available for at least four days/week

Start low and go slow, such as starting at 15 minutes then 30 minutes then

50 minutes based on individual tolerance.

Exercise options: Park at a distance from work door, shopping door, etc.;

swimming; climbing stairs; dancing; walking the dog; bicycling.

Ongoing healthy nutrition.

Meal replacement daily + 2 meals daily.

Avoid skipping meals.

3 healthy snacks daily (<100 kcal).

64 oz water daily (diet green tea, zero-calorie flavored water, unsweetened

tea or coffee, or plain water).

ANSWER

 Adolescent Depression: A Case Study Approach

Introduction

This paper addresses the case study of Justin, an 18-year-old male presenting with symptoms of depression. The discussion focuses on the health characteristics, risks, role of the nurse, health promotion strategies, and implications of social determinants of health for adolescents with depression.

Overview

Justin’s case study reveals several health characteristics and risks associated with depression in adolescents. These include fatigue, irritability, poor hygiene, low self-esteem, weight loss, and decreased motivation. The social determinants of health, such as access to mental healthcare and peer support, can influence the progression of depression in this population.

Context

Adolescent depression is a prevalent health concern, with symptoms affecting school performance and social interactions. Depression and anxiety rank high among leading causes of disability and loss of productivity. Recognizing the priority of addressing mental health in adolescents is crucial to their overall well-being and future success.

Role of the Nurse

Nurses play a pivotal role in the care of adolescents with depression. Effective communication, collaboration within multidisciplinary teams, and person-centered care are key elements. Nurses can provide emotional support, guide therapy, and facilitate communication between the adolescent and their family. The nurse’s role extends beyond medical interventions to fostering a safe and empathetic environment for emotional expression.

Health Promotion & Education

Health promotion strategies for adolescents with depression involve a combination of psychotherapies, physical activity, and nutritional support. Cognitive-behavioral therapy (CBT) and dialectical behavioral therapy (DBT) can help manage depressive symptoms. Encouraging regular exercise, practicing stress management techniques, and maintaining a balanced diet contribute to overall well-being. Providing access to crisis center hotlines and peer support programs empowers adolescents to seek help when needed.

Social Determinants of Health

The social determinants of health can impact the course of depression in adolescents. Limited access to mental health services and peer support may hinder timely intervention. Addressing these determinants requires community engagement, educational programs, and improved accessibility to mental health resources. Prioritizing mental health services in schools and promoting awareness can mitigate the impact of these determinants.

Discussion and Evaluation of Nursing Care

The nursing care for adolescents with depression should encompass both medical and psychosocial interventions. The care provided aligns with the NMBA Standards, focusing on person-centered care, communication, and collaboration. Evaluating nursing care involves assessing the effectiveness of interventions, adherence to treatment plans, and ongoing emotional support. The integration of evidence-based practices and adherence to standards ensures quality care delivery.

Conclusion

Adolescent depression is a complex issue with multifaceted implications. Addressing the specific health characteristics, risks, and social determinants of health is crucial for providing effective nursing care. By prioritizing person-centered interventions, promoting mental health awareness, and advocating for accessible resources, nurses can contribute to improved outcomes and a healthier future for adolescents with depression.