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Angela Cortez Plan case study 2022

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Primary Diagnosis: Depressive disorder Status/Condition: Stable Code Status: Full code Allergies: NKDA Admit to Unit: No need for admission to hospital. Patient is not suicidal and can be treated on an outpatient basis. “Hospitalization is necessary if suicide is a major consideration or if ...

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  • February 6, 2022
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  • 2021/2022
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Primary Diagnosis: Depressive disorder
Status/Condition: Stable
Code Status: Full code
Allergies: NKDA
Admit to Unit: No need for admission to hospital. Patient is not suicidal and can be treated on
an outpatient basis. “Hospitalization is necessary if suicide is a major consideration or if
complex treatment modalities are required” (Papadakis, McPhee, & Rabow, 2019).
Activity Level: Encourage 30-40 minutes of cardiovascular activity daily.
Studies have shown that aerobic activity and strength training can help to decrease HA1C, lipids,
blood pressure, and improve the severity of depressive symptoms (Mazyarkin, Peleg, Golani,
Sharony, Kremer, & Shamir, A. 2019).
Diet: Low fat, Low calorie
IVF (if ordered, include type and rate ): N/A
Critical Drips (If ordered, include type and rate. Do not defer to ICU Protocol): N/A
Respiratory: N/A
Medications: none
Nursing Orders: N/A
Follow Up Lab tests: none
Diagnostic testing (CXR, US, 2D Echo, etc…) Include indication for test, for example CXR
to evaluate pneumonia): None
Consults: Refer to psychotherapy. “Current standards of care recommend that adolescents
identified with depression symptoms receive further assessment, initiate antidepressant
medication and/or psychotherapy treatment, and are monitored for changes in symptoms,
especially following an antidepressant prescription” (O’Connor et al., 2016).
Patient Education and Health Promotion (address age appropriate patient education if
applicable):
 Discuss safe driving habits, including seatbelt use, texting and driving, and drinking and
driving.
 Discuss alcohol, marijuana, and tobacco use.
 Discuss violence prevention.
 Discuss delinquency prevention
 Mental health and substance use interventions


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