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7.5 Applying the Nursing Process to Depressive Disorders

The following subsections will describe how a nurse applies the nursing process and the National Council of State Board of Nursing  Clinical Judgment Measurement Model (NCJMM) to caring for clients with depression. The stages of the NCJMM are listed in parentheses next to each stage of the nursing process.

Assessment (Recognize Cues)

The initial assessment should determine if clinical depression exists, consider other conditions that might account for the client’s symptoms, and assess for risk of harm to self or others. [1]Assessing a client with a depressive disorder focuses on both verbal and nonverbal assessments. As the nurse conducts follow-up assessments, findings are compared to baseline admission assessments.  Assessment includes several components, such as a mental status examination, psychosocial assessment, cultural assessment, spiritual assessment, screening with validated tools, and review of laboratory testing results while also considering lifespan considerations.

Image of a stethoscope shape inside a circle shape

The role of the nurse in caring for clients with depression is related to primary nursing care, as well as collaboration with interprofessional team members. As a team member, the nurse may collaborate with psychiatrists, psychologists, licensed social workers, and other health care providers. The scope and practice of each team member is clearly defined within their professional licensure.

Mental Status Examination

A psychiatric interview aims to collect information from the client as well as create a therapeutic relationship between the nurse and the client. The registered nurse uses specific questions during the client’s admission process based on agency policy. See Table 7.5a for common findings when assessing a client with a depressive disorder. See expected findings for these components of a mental status examination in the “Assessment” section in Chapter 4. Critical findings that require immediate notification of the provider are bolded with an asterisk.

Table 7.5a Common Findings During A Mental Status Examination Of A Client With A Depressive Disorder

Mental Status Examination Component Common Findings in Depressive Disorders

(*Indicates immediately notify provider)
Level of Consciousness and Orientation
  • Disoriented/confused. The client may be very self-focused and may appear disoriented when others initiate conversation or talk about current events because they are unaware of what is occurring around them due to their depression.
Appearance and General Behavior
  • Disheveled. The client’s hair may not be combed, and they may be unwashed with poor dental care. They may be wearing dirty clothing with food stains and have body odor with little or no attention to self-care.
  • Sleep disturbances. The client may exhibit too much sleep (i.e., 14-18 hours daily) or have insomnia (i.e., less than 4 hours of sleep or in intervals of sleep).
  • Psychomotor retardation. The client may have a slow response with walking, talking, and reacting; may tend to stay put on the couch or in bed.
  • Vegetative signs. The client may exhibit weight loss, insomnia, constipation, and self-care deficits.
  • Avolition (reduced motivation or goal-directed behavior). For example, the client states, “I just don’t want to shower today.”
  • Anergia (low energy). For example, the client states, “I have no energy; I cannot get out of bed.”
  • Social isolation.
  • Aggressiveness and agitation.
  • *Verbal and nonverbal threats of harm.
  • *Self-harming behaviors such as cutting, picking at skin, knocking head against the wall, tightening string or items on wrists, or stabbing self with anything fashioned into a weapon.
  • *”Cheeking pills” (i.e., holding pills in mouth and not swallowing them). Clients may save medications for use in a later suicide attempt.)
Speech
  • May speak slowly in a monotone.
  • May exhibit latency (i.e., a delayed response to a question or comment). However, be aware of the client’s baseline because this may be their normal if they have a history of traumatic brain injuries, dementia, or are English language learners.
Motor Activity
  • Psychomotor retardation.
  • Motor restlessness and anxiety.
  • Inactive or not initiating self-activity or care.
Mood and Affect
  • Apathy (a lack of interest in events that one previously found enjoyable). For example, the client is no longer interested in participating in pleasurable activities. This may be verbalized or observed.
  • Anxious, irritable, angry, euphoric, tearful, or depressed.
  • Labile mood (rapid, exaggerated changes in mood). For example, a client is crying uncontrollably but when asked about the reason for crying, they state, “I don’t know, I have no reason but can’t stop crying.”
  • Dysphoria (a state of unease or dissatisfaction). For example, the client states, “I don’t like it here.”
  • Sadness.
  • Crying episodes.
  • Flat or blunted affect.
  • Constricted/restricted affect. For example, a client usually laughs at jokes and giggles at funny comments but now does neither.
  • Incongruency (a lack of alignment between response and actions). For example, a client responds that they are fine, yet their body language is curled in a fetal position with no eye contact, and they are mumbling.
  • Mood is inappropriate for the current situation.
  • *Hopelessness. For example, a client may feel there is no longer any hope for them getting better or for life improving.
  • *Worthlessness. For example, a client may have feelings of guilt regarding themselves and their depression. They may feel like a burden to others and are unable to recognize their own value.
  • *Helplessness. For example, a client does not feel in control of life events.

*Note: Hopelessness, worthlessness, and helplessness are related to an increased risk of self-injury behavior and suicide and must be reported to provider. Do not leave clients alone if statements such as these are being made.
Thought and Perception
  • Poverty of content (responds without saying anything substantive or says much more than is necessary to convey a message). For example, if a client is asked, “How did you sleep last night?,” the client answers with a long response about different brands of bedsheets without answering the question.
  • Decreased attention span.
  • Obsessions/preoccupations/ruminations. For example, a client may dwell on negative aspects of self-concept or faults and failures because they are unable to focus on anything else and thus repeat these thoughts often.
  • *Suicidal ideation.
  • *Homicidal ideation.
  • *Violence ideation.

*Note: Suicidal, homicidal, and violence ideations are characteristics of depression with recurring thoughts of death. These types of comments indicate increased risk for self-injury, suicide, or injury to others and must be reported to provider. Do not leave clients alone if statements such as these are being made.
Attitude and Insight
  • Unaware of the current situation.
  • Unable to relate to current trends or settings.
  • Lack of perception.
  • Low awareness outside of self.
  • Irritability.
Cognitive Abilities and Level of Judgment
  • The inability to make decisions, think clearly, or solve problems is common in clients with depression.

Psychosocial Assessment

As previously discussed in the “Application of the Nursing Process in Mental Health Care” chapter, a psychosocial assessment obtains additional subjective data that detects risks and identifies treatment opportunities and resources.[2],[3]:

  • Reason for seeking health care (i.e., “chief complaint”)
  • Thoughts of self-harm or suicide (both current and historical)
  • Cultural assessment
  • Spiritual assessment
  • Family dynamics
  • Current and past medical history
  • Current medications
  • History of previously diagnosed mental health disorders
  • Previous hospitalizations
  • Educational background
  • Occupational background
  • History of exposure to psychological trauma, violence, and domestic abuse
  • Substance use (tobacco, alcohol, recreational drugs, misused prescription drugs)
  • Family history of mental illness
  • Coping mechanisms
  • Functional ability/Activities of daily living

After identifying the reason the client is seeking health care, additional focused questions are used to obtain detailed information used to plan care. The mnemonic PQRSTU can be used to ask questions in an organized fashion. See Table 7.5b for a sample PQRST assessment for depression and sample responses by a client.

Table 7.5b Sample PQRSTU Questions for Assessing Depression

PQRSTU Sample Questions Sample Client Response
Provocation/Palliation

 

 “What makes your low mood or sadness better or worse?” “It gets worse when I’m alone or when I think about things I haven’t done right. Sometimes walking outside or talking to a friend helps, but I rarely have the energy to try.”
Quality “Can you describe what your low mood or sadness feels like?” “I feel numb, tired, and like I’m just going through the motions. Nothing feels enjoyable anymore.”
Region “Do you feel any physical symptoms associated with your low mood?” “Sometimes it feels like a heavy weight on my chest and shoulders. I get a lot of body aches, especially in my back and shoulders. My legs feel tired and my head feels cloudy.”
Severity “On a scale of 0 to 10, how would you rate how bad your sadness or low mood feels right now?” “It’s about a 7 on most days. On bad days it’s a 9 and I  feel like I can’t pull myself out of bed.”
Timing/Treatment

 

 “When did this sadness or low mood start? How often do you feel this way? Does it come and go or stay constant?”

 

 “It started about six months ago after I lost my job. I feel like this nearly every day. Mornings are the worst, but some days it never really lifts.”
Understanding “What do you think is causing your sadness or low mood? How do you make sense of these feelings?” “I think it’s because I lost my job and haven’t felt useful since. I feel like a failure at everything I do.”

Suicide and Self Injury Screening

Clients being evaluated or treated for depression often have suicidal ideation. It is important for the nurse to introduce suicide screening in a way that helps the client understand its purpose and normalize questions that might otherwise seem intrusive. The Patient Safety Screener (PSS-3) is an example of a brief screening tool to detect suicide risk in all client presenting to acute care settings.[4]

Non-suicidal self-injury (NSSI) refers to intentional self-inflicted destruction of body tissue without suicidal intention and for purposes not socially sanctioned. Common forms of NSSI include behaviors such as cutting, burning, scratching, and self-hitting. It is considered a maladaptive coping strategy without the desire to die. NSSI is a common finding among adolescents and young adults in psychiatric inpatient settings.[5]

Review information about suicide screening, the Patient Safety Screener, and screening for non-suicidal self-injury (NSSI) in the “Assessment” section of the Applying the Nursing Process to Mental Health Care” chapter.

Cultural Assessment

Cultural Formulation Interview (CFI) questions help nurses understand a client’s cultural background and how it influences their experience of mental health symptoms, including depression.[6] Sample CFI questions focused specifically on understanding depression within a cultural context include the following:

  • Cultural Definition of the Problem
    • “Can you describe what you’re experiencing emotionally? How would you name or label this problem?”
    • “What do people in your family or community call these kinds of feelings or mood?”
    • “How does your culture or family view feeling sad or losing interest in life?”
  • Cultural Perceptions of Cause, Context, and Support
    • “What do you think caused your sadness or low mood?”
    • “Are there events in your life, such as stress or loss, that you think may have contributed to these feelings of sadness or low mood?”
    • “Do you have any cultural or spiritual beliefs that help explain what you’re going through?”
  • Cultural Factors Affecting Coping and Help-Seeking
    • “What kinds of things have you done to cope with these feelings so far?”
    • “Are there any traditional remedies, rituals, or religious practices you use to feel better?”
    • “Have you tried to talk to anyone about these feelings, like family members, friends, religious leaders, or traditional healers?”
  • Cultural Features of the Nurse–Client Relationship
    • ““Is there anything I should know about your background or beliefs that would help me better understand you?”
    • “Do you have any concerns or hesitations you have about seeing a mental health professional?”
    • “What kind of help do you think would work best for you?”

Findings from the cultural formulation interview are used to individualize a client’s plan of care to their preferences, values, beliefs, and goals.

Reflective Questions

Reflect on how a client’s cultural values, beliefs, or preferences impact presenting symptoms, the nursing care plan, or treatment modalities. Consider the following components:

  • Religious/Spiritual beliefs
  • Language/Communication
  • Nutritional preferences
  • Fasting
  • Potential drug-food interactions
  • Rituals/Customs/Practices
  • Gender dysphoria

Spiritual Assessment

The FICA Spiritual History Tool is a widely used assessment model for evaluating a client’s spiritual beliefs and how they may influence health, illness, and coping.  FICA© is a mnemonic for the domains of Faith, Importance, Community, and Address in Care.[7] The data obtained from a FICA assessment can be helpful in understanding how clients with depression draw on spirituality or religion for support—or how spiritual distress may be contributing to feelings of depression. Spiritual distress is very common for clients experiencing serious illness, injury, loss, or the dying process, and nurses assist clients to adopt healthy coping strategies to deal with these life events. Addressing a client’s spirituality and advocating spiritual care have been shown to improve clients’ health and quality of life, including how they experience pain, cope with stress and suffering associated with serious illness, and approach end of life.[8],[9]

Table 7.5c summarizes a sample spiritual assessment questions and sample responses from a client experiencing depression.

Table 7.5c Sample FICA Spiritual Assessment Questions For Clients With Depression

Domain Sample Assessment Question Sample Client Response
Faith “Do you consider yourself spiritual or religious? What gives your life meaning?” “I was raised in a religious family that went to church every Sunday, but lately I’ve felt disconnected. I used to find comfort in prayer, but now I don’t even feel like trying.”
Importance “What importance does your faith or belief have in your life? Has it influenced how you cope with sadness or low mood?” “My faith used to mean a lot to me, but lately it’s been hard to feel hopeful that things will get better.”
Community “Are you part of a spiritual or religious community? Does participation in this community provide support when you’re feeling sad or in a low mood?” “I used to go to church regularly and event went to a prayer group, but I’ve stopped attending. I don’t want people to see me like this.”
Address in Care “How would you like me (or the health care team) to address spiritual issues during your care? Would you like to speak with a chaplain?” “I would talk with a chaplain if they will just listen and not impose their faith on me.”

Feelings of guilt, abandonment, and spiritual distress are common in individuals experiencing depression and may compound their symptoms. Nurses may recognize cues of spiritual distress and offer to connect the client with a chaplain or spiritual care services. Spiritual goals may be included in the nursing care plan if the client finds them valuable.

Family Dynamics

Family dynamics are included in a psychosocial assessment, especially for children, adolescents, and older adults. Family dynamics refers to the patterns of interactions among relatives, their roles and relationships, and the various factors that shape their interactions. Because family members rely on each other for emotional, physical, and economic support, they are primary sources of relationship security or stress. Family dynamics and the quality of family relationships can have either a positive or negative impact on an individual’s health. For example, secure and supportive family relationships can provide love, advice, and care, whereas stressful family relationships can be burdened with arguments, unhealthy relationships, and a lack of support.[10]

Unhealthy family dynamics can cause children to experience trauma and stress as they grow up. This type of exposure, known as adverse childhood experiences (ACEs), is linked to an increased risk of developing physical and mental health problems such as heart, lung, and liver disease, depression, and anxiety. Unhealthy family dynamics also correlate with an increased risk of substance use and addiction among adolescents.[11] Review information about adverse childhood experiences (ACEs) in the “Mental Health and Mental Illness” section of Chapter 1.

Screening Tools

Screening tools assess characteristics of specific mental health disorders. The screening tools listed below are examples of screenings, assessments, and question/answer prompts designed to address depressive disorders. These screening tools may be used on admission and at different times throughout the hospital or treatment stay. The findings may be used to compare and contrast client progress within the hospital stay, from a previous admission, or periodically on an outpatient basis. The registered nurse often conducts these tools as a collaborative member of the health care team.

Links to Common Screening Tools for Depressive Disorders

Laboratory Testing

There is no specific blood test to diagnose depression, but health care providers often order laboratory tests to rule out other conditions that can mimic depression symptoms, like anemia or thyroid disease. Testing may also be performed to assess overall health and kidney/liver function, especially if medication will be prescribed.  Common laboratory tests for new onset depression include complete blood count, chemistry panels, kidney and liver function tests, Vitamin B12 levels, urinalysis, thyroid stimulating hormone, rapid plasma reagin (RPR) for syphilis, human chorionic gonadotropin (HCG) for pregnancy, and toxicology screening for drug use.[12]

Life Span Considerations

Life span considerations influence how the client is assessed, as well as the selection of appropriate nursing interventions. Depressive disorders can be found across the life span from the very young to the very old. Read more about specific disorders in the “Childhood and Adolescence Disorders” chapter or the “Vulnerable Populations” chapter. It is important to individualize all interventions to the age and developmental level of the client. Review developmental stages in the “Application of the Nursing Process in Mental Health Care” chapter.

Children and Adolescents

Children may not verbalize sadness. Instead, depression often presents as irritability, frequent temper tantrums, somatic complaints (e.g., stomachaches, headaches), withdrawal from school, friends, or family, or behavioral changes like clinginess, acting out, or poor academic performance. It is important to ask children and adolescents who are withdrawn or sad about thoughts of suicide or self-harm. Adolescents may perceive a single disappointment (such as a relationship break-up) as so catastrophic they feel suicidal or begin to hurt themselves. Nurses can use play-based or art-based therapeutic techniques to facilitate a therapeutic nurse-client relationship. If a school-aged child or adolescent is suspected to have undiagnosed depression, a nurse or school counselor can refer them to a mental health professional to conduct a comprehensive assessment and plan effective treatments.

Older Adults

Depression in older adults may manifest differently as somatic symptoms (e.g., fatigue, pain, GI issues), anxiety, irritability, reduced verbal expression of sadness, or cognitive changes that may be mistaken for dementia. Furthermore, individuals with dementia are at higher risk for depression.

Depression Associated With Dementia

Dementia refers to a group of symptoms that lead to a progressive, irreversible decline in mental function severe enough to disrupt daily life caused by a group of conditions including Alzheimer’s disease, vascular dementia, frontal-temporal dementia, and Lewy body disease. Alzheimer’s disease is one of the most common forms of dementia. Alzheimer’s disease causes impaired memory and the ability to learn, reason, make judgments, communicate, and carry out daily activities. An early symptom of Alzheimer’s disease can be subtle memory loss and personality changes that differ from normal age-related memory problems. They seem to tire or become upset or anxious more easily. They do not cope well with change. For example, they can follow familiar routes, but traveling to a new place confuses them, and they can easily become lost. In the early stages of the illness, people with Alzheimer’s disease are particularly susceptible to depression.[13]

While changes in the brain that cause dementia are permanent and worsen over time, thinking and memory problems can be aggravated by untreated depression.[14] Nurses should report new symptoms of depression in clients who have been diagnosed with dementia.

Read more about dementia at the Alzheimer’s Association’s webpage.

 

Reflective Questions

How does a nurse differentiate between symptoms that could indicate depression, delirium, dementia, or psychosis?

  1. What are some common underlying medical conditions that could potentially mimic the symptoms of depression or mania in those who are elderly?
  2. What other symptoms might a client who is a child/adolescent display that would indicate the need to assess for disorders other than depression?

Diagnosis (Analyze Cues)

Mental health disorders are diagnosed by health providers using the DSM-5, similar to how medical conditions are diagnosed by trained medical professionals. Nurses create individualized nursing care plans based on the client’s response to mental health disorders. See common nursing diagnoses related to mental health disorders in the “Diagnosis” section of the “Application of the Nursing Process in Mental Health Care” chapter.

Risk for suicide is always evaluated for clients with depressive disorders because suicidal ideation is a symptom of depression. Other common nursing diagnoses with sample expected outcomes for clients with depressive disorders are discussed in the following section in Table 7.5d.

Outcome Identification (Generate Solutions)

SMART outcomes are identified in relation to the established nursing diagnoses for each client. SMART is an acronym for Specific, Measurable, Attainable/Actionable, Relevant, and Timely. Read more about outcomes identification in the “Application of the Nursing Process in Mental Health Care” chapter. Table 7.5d provides common nursing diagnoses and sample expected outcomes for each nursing diagnosis.

Table 7.5d. Common Expected Outcomes for Nursing Diagnoses Related to Depressive Disorders[15]

Nursing Diagnosis[16],[17] Sample Expected Outcomes
Risk for Suicide The client will communicate feelings and thoughts of suicide to the health care team, prior to acting on thoughts, during their inpatient stay.

*Note: Clients with depression are at higher risk of suicide when experiencing sudden euphoric recovery from major depression.[18]
Ineffective Coping/Readiness for Enhanced Coping The client will identify effective coping strategies within 24 hours of admission.

The client will engage in preferred stress management techniques by Day 3 of admission.
Self-Neglect The client will increase participation in baseline personal care each day during their stay.
Fatigue/Sleep Deprivation The client will, within one week, report feeling rested upon awakening.
Imbalanced Nutrition: Less than Body Requirements The client will eat 50% or more of their meal tray at each meal.
Constipation The client will have a soft, formed stool at least every three days during their inpatient stay.
Social Isolation The client will communicate with others during their inpatient stay by participating in daily group offerings within the milieu.
Chronic Low Self-Esteem The client will verbalize at least three personal strengths within three days of admission.
Hopelessness The client will describe plans for a positive future by discharge.
Spiritual Distress The client will identify a meaning and purpose in life within two weeks.
Readiness for Enhanced Knowledge The client will verbalize three common side effects of their medications by the end of the shift.

Planning (Generate Solutions)

Safety

Safety receives top priority when planning and implementing interventions for clients with depression. Clients with depressive disorders are monitored closely for risk of suicide, and interventions are planned according to their level of risk. Review interventions for clients at risk of suicide in the “Application of the Nursing Process in Mental Health Care” chapter.

Phases of Treatment and Recovery

As discussed earlier in this chapter, a combination of pharmacological treatments and psychotherapies are often an effective approach to treating depressive disorders. There are three phases in treatment and recovery from major depression[19]:

  • The active phase (6 to 12 weeks) is directed at reduction of depressive symptoms and restoration of psychosocial and work function. Hospitalization may be required, and medication and other biological treatments may be initiated.
  • The continuation phase (4 to 9 months) is directed at prevention of relapse through pharmacotherapy, education, and depression-specific psychotherapy. This phase focuses on maintaining the client as a functional and contributing member of the community after recovery from the acute phase.
  • The maintenance phase (1 year or more) is directed at preventing future episodes of depression. Medication may be phased out or continued.

Nurses target interventions based on the client’s current phase of treatment and recovery, their current nursing diagnoses, and established expected outcomes.

Implementation (Take Action)

Nursing Interventions for Depression Based on Categories of the APNA Implementation Standard

Nursing interventions for clients with depressive disorders can be categorized based on the American Psychiatric Nurses Association (APNA) standard for Implementation that includes the Coordination of Care; Health Teaching and Health Promotion; Pharmacological, Biological, and Integrative Therapies; Milieu Therapy; and Therapeutic Relationship and Counseling. Read more about these subcategories in the “Application of the Nursing Process in Mental Health Care” chapter. See examples of interventions for each of these categories for clients with depressive disorders in Table 7.5e.

Table 7.5e Examples of Nursing Interventions for Clients With Depressive Disorders Based on Subcategories of APNA Implementation Standard

Subcategory of the APNA Standard of Implementation The nurse will … Rationale
Coordination of Care – Collaborate with mental health professionals (e.g., therapists, psychiatrists) to ensure continuity of care.

– Communicate client assessment data, such suicidal ideation or cheeking of medications, with interprofessional team members.
– Facilitate referrals to community support resources such as support groups or home health.
– Assist with care transitions (e.g., hospital discharge to long-term care or other community-based facilities).

 Interdisciplinary collaboration ensures a comprehensive treatment plan and helps reduce relapse risk through continued support. All team members providing care must be aware of the client’s suicide risk to maintain a safe environment.
Health Teaching and Health Promotion -Educate the client and family members about depression, symptoms, and treatment options.
– Promote lifestyle modifications such as regular sleep, exercise, and healthy nutrition.- Address stigma and normalize help-seeking.		 Empowering clients with knowledge improves self-management and treatment adherence. Health promotion activities can help alleviate mild to moderate depression symptoms and reduce recurrence.
Pharmacological, Biological, and Integrative Therapies -Administer prescribed antidepressants  and monitor for side effects (e.g., GI distress, suicidality, serotonin syndrome). Open all medications in front of the client.
– Provide health teaching on medication purpose, effects, adherence, and expected timeframes for improved symptoms.-Promote positive coping strategies  such as journaling, meditation, and yoga.
– Encourage adherence to treatment (therapy, medications).		 Client understanding of their medications and potential side effects can increase medication compliance. Opening all medications in front of the client may decrease paranoia, if present. Nurses encourage resilience by adopting positive coping strategies.
Milieu Therapy -Provide a structured, safe, and supportive environment.
– Encourage participation in group therapy or therapeutic recreation.
– Use daily routines and posted schedules to increase stability and reduce decision fatigue.-Perform and document intentional rounding every 15 to 60 minutes on a varied schedule.		 A therapeutic milieu fosters a sense of safety, belonging, and predictability, which helps stabilize mood and reduce isolation. Visually rounding on every client in the milieu creates a strong safety plan for all clients and staff. Following a varied schedule prevents the client from anticipating when staff will check on them, which can reduce the ability to plan for suicide/risky behaviors.  May need some wordsmithing there.
Therapeutic Relationship and Counseling – Use active listening, empathy, and validation to build trust and a supportive nurse-client relationship.
– Explore cognitive distortions through supportive dialogue.
– Facilitate goal-setting and positive affirmations.
– Encourage verbalization of feelings, especially guilt, hopelessness, or suicidal thoughts.-Refer to spiritual supports such as chaplains, based on client preferences.-Review additional communication interventions in the “Communication Tips” subsection below.		 Providing effective therapeutic techniques for clients with depression can promote hope and positive self-esteem.

Nursing Interventions for Physiological Signs of Depression

Nursing interventions are also planned that target common physiological signs of depression and associated self-care deficits. See common interventions for these conditions in Table 7.5f.

Table 7.5f Nursing Interventions Targeting Physiological Signs of Depression and Self-Care Deficit[20]

Problem/Intervention Rationale
Nutrition

  • Offer small, high-calorie, and high-protein snacks and fluids frequently.
  • When possible, encourage family or friends to join the client during meals.
  • Encourage the client to participate in selecting food and drinks.
  • Teach about nutrient-dense foods that support mood (e.g., omega-3s, B vitamins).
  • Refer the client to a dietician if necessary.
  • Weight the client weekly and monitor trends.
  • Observe the client’s eating patterns, maintain safety. (In the hospital setting, client’s that are suicidal are given their food on a tray with plastic silverware, food in styrofoam containers, etc to reduce the risk of injury to self/others).
 Poor nutrition increases the risk for physical illness and improving nutrition can help stabilize energy and mood. Small, frequent snacks are more easily tolerated than large portions of food if the client has a loss of appetite. Fluids prevent dehydration and minimize constipation.

Eating is a social event. Eating with loved ones reinforces the idea that someone cares about them and can serve as an incentive to eat. The client is more likely to eat foods they prefer. A dietician can help create an individualized diet plan. Monitoring the client’s status provides data for evaluating effectiveness.
Sleep

  • Assess sleep patterns and disturbances.
  • Encourage consistent sleep-wake cycles and limit daytime naps. Provide periods of rest after activities, if needed.
  • Encourage the client to get up and dress and stay out of bed during the day.
  • Encourage relaxation measures in the evening, such as a warm bath, warm milk, or soothing music.
  • Avoid caffeinated beverages.
 Sleep disruption is a hallmark of depression and worsens emotional regulation. Promoting good sleep hygiene helps restore circadian rhythm and reduce fatigue Minimizing sleep during the day and establishing routines increase the likelihood of restful sleep at night. Relaxation techniques induce sleep. Decreasing caffeine intake increases the possibility of sleep.
Elimination (Constipation)

  • Monitor frequency of bowel movements.
  • Encourage fluids and foods high in fiber.
  • Provide periods of exercise.
  • Evaluate medications for side effects affecting elimination (e.g., TCAs, SSRIs).
  • Support toileting routines and privacy.
  • Evaluate the need for a bowel management program with stool softeners and laxatives.
 Many depressed clients are constipated, so frequency of bowel movements should be monitored. Fluids, fiber, and exercise stimulate peristalsis and soften stools. Bowel management programs may be needed to avoid constipation or fecal impaction. Addressing elimination improves physical comfort and self-esteem.
Fatigue/Energy Deficit

  • Schedule activities during periods of higher energy (usually morning).
  • Promote light physical activity, such as walking or stretching.
  • Provide rest periods without encouraging excessive sleeping.
  • Use motivational interviewing to support gradual engagement according to the treatment plan.
 Depression often causes feelings of extreme fatigue. Light exercise improves endorphin levels and sleep quality. Motivational interviewing helps encourage clients to set personal goals and participate in the treatment plan.
Self-Care Deficits

  • Assess ability to perform ADLs (e.g., bathing, grooming, dressing).
  • Offer verbal prompts, encouragement, and step-by-step support. When appropriate, give step-by-step reminders, such as “Wash the right side of your face and now your left.”
  • Establish a simple daily hygiene routine.
  • Reinforce successes positively.
 Depression impairs motivation and concentration, leading to neglect of self-care.  Slowed thinking and difficulty concentrating make organizing simple tasks difficult. Supporting ADLs restores self-worth and promotes dignity. Being clean and well-groomed can improve self-esteem.

Communication Tips for Clients with Depressive Disorders

Some clients with depression may be so withdrawn they are unwilling or unable to speak. Sitting with them in silence may feel like a waste of time, but nurses should be aware that providing therapeutic presence can be meaningful in supporting the client with depression. Helpful communication techniques for clients with depression and their rationale are described in the following box.

Communication Tips for Clients with Depressive Disorders[21]

  • Use a calm, soft, and patient tone.
    • Rationale: Depressed individuals may feel overwhelmed or hopeless; a soft tone reduces pressure and invites connection.
  • Allow extra time for responses.
    • Rationale: Psychomotor retardation (slowed thinking or movement) is common in depression. Waiting without rushing encourages the client to participate without feeling inadequate.
  • Use simple, concrete words and allow the client time to respond.
    • Rationale: Depression can impair concentration and processing. Short, straightforward phrases are easier to understand and less cognitively demanding.
  • Acknowledge and validate feelings.
    • Rationale: Statements like “It sounds like things have been really difficult for you” show empathy and help the client feel seen and understood, rather than judged.
  • Be alert for signs of suicidal ideation and ask directly.
    • Rationale: Use nonjudgmental phrasing like, “Sometimes people with depression have thoughts of not wanting to live. Have you felt that way?” Asking does not increase risk for suicide and opens a vital safety dialogue. People often experience relief and decreased feelings of isolation when they share thoughts of suicide.
  • Avoid platitudes such as, “Just think positive,” “Everyone feels down once in a while,” or “Just snap out of it.”
    • Rationale: Platitudes invalidate the individual’s feelings and can increase feelings of guilt or worthlessness because they cannot “snap out of it.”
  • Normalize their experience.
    • Rationale: Letting clients know that “many people with depression feel this way” helps reduce shame and stigma, and reassures them they are not alone.
  • When a client is silent, use the technique of making observations, such as “There are new pictures on the wall,” or “You are wearing new shoes.”
    • Rationale: When an individual is not ready to talk, direct questions can raise their anxiety levels.  Respect the client’s silence or limited responses. Pointing out objects in the environment can draw the person into reality.  Being present without pressuring them to talk builds trust and shows unconditional support.
  • Offer hope in small, realistic ways.
    • Rationale: Gently reinforce that treatment is available and recovery is possible, e.g., “There are things we can try that have helped others feel better.”

Nurses counsel individuals with depression to help them explore positive coping strategies[22]:

  • Encourage stress management techniques such as exercise, good sleep, and healthy food choices.
  • Promote the formation of supportive relationships such as peer support and support groups to reduce social isolation and enable the individual to work on personal goals and relationship needs.
  • Provide information about spiritual support as the individual defines it, such as chaplain or pastoral visits or spending time in nature; many people find strength and comfort in spiritual and/or religious activities.
  • Help the client reconstruct a healthier and more hopeful attitude about the future (without providing false reassurance).

Collaborative Mental Health Treatments

Nurses assist in implementing collaborative interventions based on the client’s treatment plan. Review collaborative mental health treatments and common medications used to treat depression in the “Treatments for Depression” section of this chapter.

Patient Education Regarding Antidepressant Medications

Nurses educate clients about their medications, including the manner in which they work, common side effects, and issues to report to their provider. Clients taking antidepressants should also be educated regarding the following considerations[23]:

  • When taking antidepressants, it is important to follow the instructions on how much to take. Some people start to feel better a few days after starting the medication, but it can take four to eight weeks to feel the most benefit. Antidepressants work well and are safe for most people, but it is still important to talk with your mental health care provider if you have side effects such as sexual dysfunction, weight gain, dizziness, nausea, palpitations, drowsiness, insomnia, or anxiety. Side effects may go away as your body adjusts to the medication, but in some cases, switching to a different medication may be required.
  • Don’t stop taking an antidepressant without first talking to your health care provider. Stopping your medicine suddenly can cause symptoms or worsen depression.
  • Antidepressants cannot solve all of your problems. Antidepressants work best when combined with psychotherapy and healthy coping strategies. If you notice that your mood is getting worse or if you have thoughts about hurting yourself, it is important to call your provider right away.
  • Some people who are depressed may think about hurting themselves or committing suicide (taking their own life). If you are having thoughts about committing suicide‚ please seek immediate help by calling your provider, 911, or 1−800−273−TALK to reach a 24−hour crisis center that provides free‚ confidential help to people in crisis.
  • Some antidepressants may cause risks to the baby during pregnancy. Talk with your provider if you are pregnant or might be pregnant or if you are planning to become pregnant.
  • For individuals who are very depressed or suicidal, it is important to provide close monitoring when the individual first starts taking an antidepressant medication. Often an individual may have increased energy to make a suicidal attempt when they first begin a medication, whereas previously they may have had suicidal thoughts but lacked the energy to make an attempt.

Supporting Family Members

It is important to support the family members and significant others who are living with an individual with a depressive disorder. Read tips on living with someone with depression in Figure 7.9.[24]

 

Image showing world health organization's poster for supporting someone with depression
Figure 7.9 Supporting Family Members and Significant Others

Evaluation (Evaluate Outcomes)

Evaluation of the client’s progress towards meeting expected outcomes occurs continuously throughout the treatment phase. Evaluation includes comparing results from screening tools, reviewing laboratory results, and monitoring the effectiveness of prescribed medications, treatments, and nursing interventions. Based on the evaluation findings, the nursing care plan may be modified, or new interventions or outcomes may be added.

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  10. This work is a derivative of StatPearls by Jabbari & Rouster and is licensed under CC BY 4.0 ↵
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