Introduction
This nursing note aims to comprehensively assess Mr. Cortez’s current mental health condition. Mental health conditions encompass various disorders, such as anxiety, schizophrenia, addictive behaviors, and depression (Singh et al., 2022). During the telehealth session, Mr. Cortez exhibited a commendable level of alertness and orientation. He was lucid and able to engage in a meaningful conversation. Moreover, Cortez reported no significant changes in his condition since his last visit, prompted by a traumatic stabbing incident. It is also vital to acknowledge that Mr. Cortez is currently maintaining a full-time job, working 40 hours a week at Universal Cleaning Company. This employment situation may contribute to his occasional experiences of depression, mainly attributed to work-related stress and family issues.
Situations
The nurse conducted an auditory telehealth session with Mr. Cortez, who resides in the vibrant city of Washington, D.C. This telehealth session was meticulously designed to address various facets of his mental health treatment plan. It encompassed critical elements such as medication management, appointment compliance, and discussions concerning his overall emotional and psychological well-being. Mr. Cortez actively and willingly participated in this session, displaying an admirable level of engagement and cooperation (Singh et al., 2022). During the session, Mr. Cortez openly shared his concerns, specifically focusing on the significant stress he has been grappling with lately. This stress has manifested itself in several ways, affecting his ability to sleep and hampering his productivity at work.
Interventions
The nurse initiated this telehealth encounter with a warm and empathetic greeting, creating a conducive atmosphere for open communication. Mr. Cortez was encouraged to express his thoughts, emotions, and concerns, fostering trust and therapeutic alliance. The nurse assumed the role of an active and empathetic listener, attentively absorbing Mr. Cortez’s narrative of his mental health history. This step was pivotal in gaining insights into his unique experiences and challenges. Beyond active listening, the nurse extended her role to an educator, providing Mr. Cortez with invaluable information about the disease processes associated with his condition. Furthermore, the nurse offered practical guidance on lifestyle modifications that could potentially enhance Mr. Cortez’s overall well-being. It is paramount to highlight that the nurse precisely documented Mr. Cortez’s demographic information.
The records indicate that Mr. Cortez is 56 years old and lives Washington D.C. the medical profile suggests that he has a complicated interaction of mental wellness issues, including Post-Traumatic Stress Disease (PTSD). This is a general stress disease, and significant depression, recurrent events with an undefined specifier. In addition, Mr. Cortez was not using any mental drugs during this interaction. However, he expressed a commendable willingness to fully engage in his prescribed treatment plan. The nurse’s guidance extended to encouraging Mr. Cortez to prioritize compliance with the recommendations and appointments set forth by his mental health care team.
The underlying principle behind this counsel is the recognition that adherence to treatment regimens is paramount in improving one’s mental health status. It is a foundational pillar in the journey towards emotional stability and well-being. Additionally, Mr. Cortez received explicit instructions to schedule an appointment with a Nurse Practitioner. This appointment was deemed essential for conducting a current psychiatric evaluation, which would provide critical insights into the trajectory of his condition and tailor treatment accordingly.
Furthermore, the nurse undertook a multifaceted approach to address the pervasive stressors in Mr. Cortez’s life. Mr. Cortez was enlightened about the myriad benefits of physical activity and social engagement. The nurse emphasized the positive impact of spending quality time with family and friends to foster emotional resilience and support. Mr. Cortez was informed how chronic stress can considerably affect one’s health. Stress can elevate blood pressure and blood sugar levels, culminating in chronic diseases (Memiah et al., 2022). This holistic approach to stress management seeks to alleviate psychological distress and safeguard his physical health. Moreover, the nurse comprehensively evaluated Mr. Cortez’s support system and coping mechanisms. This thorough assessment was instrumental in identifying areas that required adjustment to effectively address the stressors present in his life.
Responses
During the telehealth session, the nurse adopted an empowering stance, equipping Mr. Cortez with the knowledge and resources to take an active role in his healing journey. This empowerment manifested in an enlightening discussion about medical appointment compliance and the significance of effective communication with the clinical team. Mr. Cortez, demonstrating admirable agency and insight, expressed a significant desire to seek guidance from a psychiatrist. He recognized the need for specific interventions to contribute to emotional stability, and this proactive attitude was worthy. Meaningfully, Mr. Cortez secured an appointment with a psychiatrist on the same day. This timely action underscores his commitment to addressing his mental health concerns head-on. His request for additional information and willingness to engage in frequent visits with the nurse further emphasize his dedication to his well-being.
Plan
In coordination with a Clinical Social Worker (CSW), the nurse aims to restore and fortify essential elements in Mr. Cortez’s life, including trust, empathy, and generosity. These elements are foundational to nurturing and sustaining healthy relationships, which play a pivotal role in successfully implementing his treatment plan. In addition, another telehealth session has been thoughtfully scheduled to continue working toward the mutually agreed-upon objectives. The CSW, operating with the nurse, would assist Mr. Cortez in engaging in stress-relieving activities. The CSW would also provide indispensable support by offering timely reminders about Mr. Cortez’s upcoming appointments, ensuring that he remains steadfast in his commitment to his well-being. As part of the ongoing support plan, the nurse would proactively send Mr. Cortez additional resources tailored to his unique needs, providing him with valuable tools to aid his recovery journey.
Mr. Cortez’s nursing assessment is a testament to the importance of a comprehensive, patient-centered approach in addressing major depression. Through the amalgamation of active engagement, education, empowerment, and collaborative support, Mr. Cortez is poised to significantly improve his mental health and overall well-being. The forthcoming collaboration with the CSW and providing ongoing support resources would further enhance his prospects for recovery and emotional stability.
References
Memiah, P., Biadgilign, S., Kuhlman, J., Cook, C., Mburia, P., Kingori, C., … & Hawkins, M. (2022). Allostatic load, single, and dual chronic conditions: national health and nutrition examination survey evidence. Metabolic Syndrome and Related Disorders, 20(2), 104-113.
Singh, V., Kumar, A., & Gupta, S. (2022). Mental health prevention and promotion—A narrative review. Frontiers in Psychiatry, 13, 898009.
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