Before creating a nursing care plans for depression we are learning about depression. Depression is an affective disorder characterized by a sad mood, lack of ideas, and psychomotor retardation.
Depression is characterized by
- Beelings of unworthiness
- Deep sadness
- Anxiousness
- Apathy and hopelessness
- Loss of interest and pleasure in usual activities is common
- Physical activity or restlessness
- Unwanted weight loss
- Decreased ability to concentrate or solve problems
- Changes in sleeping, eating, and libido
- Nursing diagnosis for depression
Nursing diagnosis and their intervention with rationale
Insufficient knowledge
Related to unfamiliarity with the causes, signs, symptoms, and treatment of depression
Desired outcome:
The patient and key caregivers report accurate information about at least two of the possible causes of depression, four of the signs and symptoms of depression, and the use of medication, psychotherapy, and/or electroconvulsive therapy (ECT) as treatment.
| Nursing interventions | Rationale |
| Assess the patient’s and caregiver’s knowledge of depression and its causes. | Depression is a physiological disorder caused by the interaction of many factors such as stress, loss, imbalance in brain chemistry, and genetics. Many people believe that depression is due to character flaws. This belief contributes to the stigma faced by those suffering from depression and hinders the seeking of treatment. |
| Inform the patient and caregiver about the major symptoms of depression. | Many people believe that depression equates to sadness and fail to recognize the many other signs and symptoms that make this a holistic disorder. |
| Explain that depression is treatable. | Medications are usually indicated for treatment. They do not solve the stressors or problems that triggered or caused the depression, but they provide the energy to cope with those problems. A combination of antidepressants and psychotherapy generally helps relieve symptoms of depression within a few weeks. Psychotherapy alone may be indicated for mild depression due to situational causes. |
| Explain the use of ECT when appropriate. | ECT may be used to treat patients who do not respond to antidepressant medication after several attempts and psychotherapy. It is generally well-tolerated and is given as a series of treatments. |
Hopelessness
Related to losses, stressors, and the distressing symptoms of depression.
| Nursing interventions | Rationale |
| Assess individual signs of hopelessness. | This helps to focus attention on areas of individual need. These signs may include decreased physical activity, social withdrawal, and patient expressions that indicate hopelessness and despair. |
| Assessment of unhealthy behaviors used to cope with feelings. | Patient may have attempted to overcome feelings of hopelessness with harmful and ineffective behaviors. |
| Encourage patient to identify and verbalize feelings and perceptions | The process of identifying feelings that underlie and drive behavior allows the patient to take control of his or her life. |
| Give the patient hope by being realistic about his or her strengths and resources. | Patients may feel hopeless, but it is helpful to hear positive statements from others |
| Help the patient identify areas of life that are under his or her control. | A patient’s emotional state may interfere with problem-solving. Help may be needed to identify areas that are under his control and to gain clarity about how to take control. |
| Encourage the patient to take responsibility for self-care, such as setting realistic goals, planning activities, and making independent decisions. | Helping patients set realistic goals increases sense of control and satisfaction when goals are achieved, reducing feelings of hopelessness. |
| Help the patient identify areas of life that he or she cannot control. Discuss the feelings associated with this lack of control. | The patient needs to identify and resolve the feelings associated with the inability to control certain life situations before acceptance can be achieved and hopelessness becomes possible. |
| Encourage the patient to seek spiritual bits of help that can provide hope. | Many people find that spiritual beliefs and practices are a great source of hope. |
| Conduct a suicide assessment to determine the level of suicide risk. | If the risk is high, hospitalization is required. |
| Inform patients of crisis intervention services such as suicide hotlines and other resources. | It is critical to provide patients with resources for support and safety when thoughts and feelings about suicide are difficult to manage. |
Risk for Suicide
Associated with depressed mood and feelings of hopelessness.
| Nursing interventions | Rationale |
| Conduct an initial suicide assessment using a standardized assessment tool such as the SAD PERSONS Suicide Risk Assessment Scale. | The degree of hopelessness expressed by the patient is important in assessing suicide risk. Suicide risk is increased if the patient has already attempted suicide or if there is a family history of suicide and depression. |
| Reassess for suicidality, especially during times of change. | Changes such as an improvement in the patient’s mood, a change in medication regimen, initiation of discharge planning, and increasing withdrawal are all signals that require reassessment for suicidality. Suicide risk is greatest in the first few weeks after treatment begins. The patient may be doing somewhat better, but not yet well enough to feel hopeful, and may already have enough renewed energy to entertain suicidal thoughts. |
| Administer an antidepressant or remind the patient of the importance of taking the medication as prescribed. | Suicidal ideation is a symptom of depression that can be alleviated with appropriate medication treatment. |
| Educate caregivers about safety precautions and watch for changes in the patient’s behavior and/or expression that may indicate an increase in suicidal ideation | Calling available support provides a safety net for the patient and communicates that he or she is not alone, but that others are concerned and involved in care. |
| Monitor at least every 15 minutes for moderate risk, preferably staggering monitoring times so that the patient does not take advantage of a guaranteed window of opportunity for suicidal behavior. Constant individual monitoring for serious risk. Place the patient in a room near the nurse’s station. Do not assign him to a single room. Accompany the patient to all activities outside the ward or confine him to the ward. Require the patient to remain within sight of staff at all times. | Close observation may prevent suicide attempts. |
| Remove items such as belts, scarves, razor blades, shoelaces, scissors – anything that could be used for self-harm. Check all items brought into the unit by patients. Instruct family members not to bring dangerous items into the unit. | This provides safety in the environment and eliminates potential suicide weapons. |
| Supervise the patient when they are in the restroom. The door must remain open and a staff member must remain outside. | It is important to eliminate all opportunities for self-harming behavior. |
| Perform an oral exam to ensure the patient is swallowing the medications given to them. | This will prevent medications from being saved up to be overdosed or thrown away and not spoken. |
| Ensure that nursing rounds are conducted at frequent but irregular intervals, especially at times when staff are predictably busy, such as a shift change. | It is important that staff monitoring is not predictable, otherwise patients would be able to detect a possible suicide time. In addition, it is important that the patient’s location is known at all times. |
| Routinely check the environment for hazards and ensure the environment is safe. | Minimizing opportunities for self-harm (e.g., locking doors, windows, and access to stairs and the roof, and monitoring cleaning, chemical, and repair materials) is an ongoing concern that requires constant vigilance. |
| Initiate a safety plan with the patient. | Involving the patient in creating a safety plan promotes trust between patient and caregiver while supporting self-care and monitoring. |
Grieving
Related to an actual, perceived, or anticipated loss
| Nursing interventions | Rationale |
| Assess losses that have occurred in the patient’s life. Discuss the significance that these losses have had for the patient. | Many people deny the significance/impact of a loss. They fail to recognize, acknowledge, or talk about their pain and act as if everything is fine. This has a cumulative effect on the individual. Denial requires physical and psychological energy. When people become clinically depressed, it is likely to be in a physically and emotionally exhausted state. |
| Discuss cultural practices and religious beliefs, as well as how the patient has dealt with past losses. | Cultural practices and religious beliefs influence how people express and accept the grieving process. |
| Encourage the patient to name and verbalize feelings and explore the relationship between feelings and the event | Verbalizing feelings in a nonthreatening environment can help patients cope with unresolved issues that may be contributing to depression. It also helps patients relate the reaction (feeling) to the stressor or triggering event. |
| Discuss healthy ways to identify and manage underlying feelings of hurt, rejection, and anger. | This helps the patient expand his or her repertoire of coping strategies. |
| If indicated, share stories of how others have coped with similar situations. | This not only highlights possible solutions, but also gives the impression that the problem is manageable. |
| Communicate the normal stages of grief and acknowledge the reality of associated feelings such as guilt, anger, and powerlessness. | This information helps the patient recognize the normalcy of the feelings and may alleviate some of the guilt that arises from these feelings. |
| Help the patient name the problem, recognize the need to address the problem differently, and fully describe all aspects of the problem. | Before patients can agree to change, they need to be clear about what the problem is. |
| Help the patient recognize early signs of depression and find ways to alleviate those signs. Help formulate a plan that addresses the need for outside support if symptoms persist and worsen. | This actively involves the patient and conveys the message that the patient is not powerless, but that there are options. |
Chronic Low Self-Esteem
in connection with the repeated negative reinforcement of self-evaluation, which is symptomatic of depression
| Nursing interventions | Rationale |
| Provide positive reinforcement for all observable performance. | Patients with low self-esteem do not benefit from flattery or insincere praise. Honest, positive feedback boosts self-esteem. |
| Encourage patients to participate in simple recreational activities or art projects and progress to more complex activities in a group setting. | Initially, patients may be overwhelmed to participate in activities involving more than one person. |
| If the patient continues to make negative comments about him/herself, limit the amount of time you listen to these negative comments. | Time limits provide the patient with a safe place and time to vent negative feelings and demonstrate conscious interruption of negative thoughts. For example, agree to listen to 10 minutes of negativity followed by 10 minutes of positive comments. |
| Teach techniques for thought interruption and positive reframing. | Many depressed people engage in self-critical thinking and need to learn to consciously interrupt this type of thinking and replace it with positive thinking. |
| Explore the patient’s personal strengths and suggest making a list that can serve as a reminder when negative thoughts recur. | A written list can help the patient during difficult times. |
Deficient Knowledge
Related to unawareness of the use of medications for depression, including potential side effects.
| Nursing interventions | Rationale |
| Assess the patient’s level of knowledge about the use of medication for Improve depressive symptoms. | It is important to find out what patients know and do not know about the medications prescribed to treat their depression. Patients often have misconceptions and inaccurate ideas about medications, which interferes with adherence to the prescribed medication regimen. |
| Provide education about the physiologic effects of the prescribed antidepressant and how it relieves symptoms of depression. | Many depressed patients refuse to take medication because they fear becoming “addicted”; however, antidepressants are not addictive. Informing the patient about the physiologic effects of the medication contributes to treatment adherence. |
| Pointing out the importance of taking the medication at the prescribed dose and intervals. | Some medications require specific blood levels to be therapeutic; therefore, patients must take them at the prescribed dose and time. |
| Provide education on the side effect profile of the prescribed medication, including measures to address these effects, for the following cases: | Each class of antidepressants has a specific side effect profile. Knowing what side effects to expect, how to manage these side effects, and the duration of these side effects is important to ensure treatment adherence. |
| Watch for anticholinergic effects (other than trazodone) such as hesitant urination or urinary retention, dry mouth, blurred vision, sedation, hypotension, and risk of falls due to dizziness associated with hypotension. | These are common side effects that can be managed by encouraging patients to drink adequate water and avoid exertion in high temperatures and activities that require mental alertness while adjusting to the drug. |
| Watch for risk of seizures. | Risk is moderate with trazodone and increases with amoxapine and maprotiline. |
| Watch for risk of cardiac toxicity. In patients older than 40 years, obtain ECG before treatment and periodically thereafter. | The risk is minimal with amoxapine and trazodone. There is a significant risk with maprotiline. |
The patient should be advised that mild sedation and hypotension may occur. | These are common side effects of MAO inhibitors. |