The provided documentation details the case of Madeline Moore, a 45-year-old woman presenting with symptoms indicative of borderline clinical depression, exacerbated by recent life stressors including divorce, job loss, and limited social support. The documentation focuses on assessment findings and potential nursing interventions. It also briefly touches upon the physiological and psychological complications associated with alcohol withdrawal, though this is not directly related to Madeline Moore’s case. This article will summarize the clinical presentation of Madeline Moore, outline relevant diagnostic information, and detail potential nursing interventions based on the provided materials.
Client Presentation and Diagnostic Findings
Madeline Moore is a 45-year-old female seeking care for symptoms of depression. She has a history of experiencing depression but is not currently taking any medication for it. Her current medication regimen includes a multivitamin and a calcium supplement. A significant life event contributing to her current state is an ongoing divorce characterized by both emotional and physical abuse. She reports feeling safe, having moved out of the marital residence.
The Beck Depression Inventory administered by the nurse yielded a score of 20, classifying her depression as borderline clinical. In addition to this score, Madeline reports several additional symptoms consistent with a depressive disorder. These include a weight loss of 30 pounds over the past two months, a loss of appetite, and difficulty coping due to a perceived lack of social support. Her primary support system consists of a friend who no longer resides nearby and her parents. Currently, she is residing with her parents.
Further contributing to her distress is recent job loss due to company downsizing, occurring three months prior to seeking care. She has been unable to secure full-time employment and is currently working part-time, insufficient to cover her living expenses. She explicitly denies any thoughts of self-harm or harm to others.
Nursing Interventions: Monitoring and Assessment
Based on the provided documentation, a key nursing intervention is the regular monitoring of Madeline’s weight. This is specifically indicated to observe for continued weight loss or stabilization of her weight. The documentation highlights this as a single, actionable step. This monitoring should be conducted in conjunction with a comprehensive assessment of her nutritional intake and appetite.
The documentation also suggests a focus on diagnosis and interventions related to depression symptoms and a lack of social support. The “ACTIVE LEARNING TEMPLATE” referenced in one source emphasizes the importance of understanding the “WHO? WHEN? WHY? HOW?” of nursing care. While the template itself is not fully populated in the provided materials, it underscores the need for a structured approach to care planning.
Understanding Alcohol Withdrawal (Related Concept)
Although not directly applicable to Madeline Moore’s case, the documentation briefly addresses the importance of understanding the physical and mental problems associated with alcohol withdrawal. It notes that these problems can range from mild to severe and can depress the entire system. The documentation references underlying principles and nursing interventions related to alcohol withdrawal, but does not provide specific details. This suggests a broader scope of knowledge expected of nurses, encompassing a range of potential patient presentations.
Active Learning Template and Concept Prioritization
The documentation references an “ACTIVE LEARNING TEMPLATE” designed to facilitate student understanding of concept prioritization in nursing care. This template is intended to guide students in considering the “WHO? WHEN? WHY? HOW?” of nursing interventions. The template is specifically linked to a review module covering chapters 18 and 31, suggesting a curriculum framework for nursing education. The template’s focus on underlying principles and nursing interventions highlights the importance of evidence-based practice and critical thinking in clinical decision-making.
Considerations for Social Support and Coping Mechanisms
The documentation explicitly identifies a lack of social support as a contributing factor to Madeline’s difficulty coping. While the documentation does not detail specific interventions to address this, it implies the need to explore strategies to enhance her social network and coping mechanisms. This could involve connecting her with community resources, support groups, or mental health services. Further assessment is needed to determine the nature of her relationship with her parents and the extent to which they can provide emotional support. The documentation notes her friend no longer lives in the area, indicating a loss of a previously available support system.
Weight Management and Nutritional Assessment
The documentation specifically highlights the need to monitor Madeline’s weight due to the reported 30-pound weight loss over two months. This weight loss, coupled with a loss of appetite, suggests a potential nutritional deficit. A comprehensive nutritional assessment is warranted to determine her current dietary intake, identify any nutritional deficiencies, and develop a plan to address them. This assessment should consider her financial constraints, as she is currently unable to afford independent living due to part-time employment.
Depression Management and Further Assessment
The Beck Depression Inventory score of 20 indicates borderline clinical depression. This finding warrants further assessment to determine the severity of her symptoms, identify any underlying contributing factors, and develop an appropriate treatment plan. This plan may include psychotherapy, medication, or a combination of both. The nurse should also assess for any suicidal ideation, despite the client’s current denial of such thoughts. Ongoing monitoring of her mood and symptoms is essential.
Conclusion
The provided documentation presents a case study of Madeline Moore, a 45-year-old woman experiencing symptoms of borderline clinical depression, complicated by recent life stressors and a lack of social support. Key findings include a Beck Depression Inventory score of 20, significant weight loss, loss of appetite, and financial instability. Nursing interventions should focus on regular weight monitoring, comprehensive assessment of her depression and nutritional status, and exploration of strategies to enhance her social support network and coping mechanisms. While the documentation briefly touches upon alcohol withdrawal, this is not directly relevant to Madeline Moore’s case. The “ACTIVE LEARNING TEMPLATE” emphasizes the importance of a structured approach to care planning, considering the “WHO? WHEN? WHY? HOW?” of nursing interventions.