APPLICATION OF THE NURSING PROCESS: DEPRESSION
The nurse can collect assessment data from the client and family or significant others, previous chart information, and others involved in the support or care. It may take several short periods to complete the assessment because clients who are severely depressed feel exhausted and overwhelmed. It can take time for them to process the question asked and to formulate a response. It is important that the nurse does not try to rush clients because doing so leads to frustration and incomplete assessment data.
To assess the client’s perception of the problem, the nurse asks about behavioral changes: when they started, what was happening when they began, their duration, and what the client has tried to do about them. Assessing the history is important to determine any previous episodes of depression, treatment, and client’s response to treatment. The nurse also asks about family history of mood disor-ders, suicide, or attempted suicide.
Many people with depression look sad; sometimes they just look ill. The posture often is slouched with head down, and they make minimal eye contact. They have psychomotor retardation (slow body movements, slow cognitive processing, and slow verbal interaction). Responses to questions may be minimal, with only one or two words. Latency of response is seen when clients take up to 30 seconds to respond to a question. They may answer some questions with “I don’t know” because they are simply too fatigued and overwhelmed to think of an answer or respond in any detail. Clients also may exhibit signs of agitation or anxiety such as wringing their hands and having difficulty sitting still. These clients are said to have psychomotor agitation (increased body movements and thoughts), which includes pacing, accelerated think-ing, and argumentativeness.
Clients with depression may describe themselves as hope-less, helpless, down, or anxious. They also may say they are a burden on others or are a failure at life, or they may make other similar statements. They are easily frustrated, are angry with themselves, and can be angry with others (APA, 2000). They experience anhedonia, losing any sense of pleasure from activities they formerly enjoyed. Clients may be apathetic, that is, not caring about self, activities, or much of anything.
Their affect is sad or depressed or may be flat with no emotional expressions. Typically, depressed clients sit alone, staring into space or lost in thought. When addressed, they interact minimally with a few words or a gesture. They are overwhelmed by noise and people who might make demands on them, so they withdraw from the stimulation of interaction with others.
Clients with depression experience slowed thinking pro-cesses: their thinking seems to occur in slow motion. With severe depression, they may not respond verbally to ques-tions. Clients tend to be negative and pessimistic in their thinking, that is, they believe that they will always feel this bad, things will never get any better, and nothing will help. Clients make self-deprecating remarks, criticizing them-selves harshly and focusing only on failures or negative attributes. They tend to ruminate, which is repeatedly going over the same thoughts. Those who experience psychotic symptoms have delusions; they often believe they are responsible for all the tragedies and miseries in the world.
Often clients with depression have thoughts of dying or committing suicide. It is important to assess suicidal ideation by asking about it directly. The nurse may ask, “Are you thinking about suicide?” or “What suicidal thoughts are you having?” Most clients readily admit to suicidal thinking.
Some clients with depression are oriented to person, time, and place; others experience difficulty with orientation, especially if they experience psychotic symptoms or are withdrawn from their environment. Assessing general knowledge is difficult because of their limited ability to respond to questions. Memory impairment is common. Clients have extreme difficulty concentrating or paying attention. If psychotic, clients may hear degrading and belittling voices or they may even have command halluci-nations that order them to commit suicide.
Clients with depression experience impaired judgment because they cannot use their cognitive abilities to solve problems or to make decisions. They often cannot make decisions or choices because of their extreme apathy or their negative belief that it “doesn’t matter anyway.”
Insight may be intact, especially if clients have been depressed previously. Others have very limited insight and are totally unaware of their behavior, feelings, or even their illness.
Sense of self-esteem is greatly reduced; clients often use phrases such as “good for nothing” or “just worthless” to describe themselves. They feel guilty about not being able to function and often personalize events or take responsi-bility for incidents over which they have no control. They believe that others would be better off without them, a belief which leads to suicidal thoughts.
Clients with depression have difficulty fulfilling roles and responsibilities. The more severe the depression, the greater the difficulty. They have problems going to work or school; when there, they seem unable to carry out their responsibilities. The same is true with family responsibili-ties. Clients are less able to cook, clean, or care for chil-dren. In addition to the inability to fulfill roles, clients become even more convinced of their “worthlessness” for being unable to meet life responsibilities.
Depression can cause great strain in relationships. Fam-ily members who have limited knowledge about depression may believe clients should “just get on with it.” Clients often avoid family and social relationships because they feel overwhelmed, experience no pleasure from interactions, and feel unworthy. As clients withdraw from relationships, the strain increases.
Clients with depression often experience pronounced weight loss because of lack of appetite or disinterest in eat-ing. Sleep disturbances are common: either clients cannot sleep, or they feel exhausted and unrefreshed no matter how much time they spend in bed. They lose interest in sexual activities, and men often experience impotence. Some clients neglect personal hygiene because they lack the interest or energy. Constipation commonly results from decreased food and fluid intake as well as from inac-tivity. If fluid intake is severely limited, clients also may be dehydrated.
Depression Rating Scales
Clients complete some rating scales for depression; mental health professionals administer others. These assessment tools, along with evaluation of behavior, thought pro-cesses, history, family history, and situational factors, help to create a diagnostic picture. Self-rating scales of depres-sive symptoms include the Zung Self-Rating Depression Scale and the Beck Depression Inventory. Self-rating scales are used for case finding in the general public and may be used over the course of treatment to determine improve-ment from the client’s perspective.
The Hamilton Rating Scale for Depression (Table 15.6) is a clinician-rated depression scale used like a clinical interview. The clinician rates the range of the client’s behaviors such as depressed mood, guilt, suicide, and insomnia. There is also a section to score diurnal varia-tions, depersonalization (sense of unreality about the self), paranoid symptoms, and obsessions.
The nurse analyzes assessment data to determine priorities and to establish a plan of care. Nursing diagnoses com-monly established for the client with depression include the following:
· Risk for Suicide
· Imbalanced Nutrition: Less Than Body Requirements
· Ineffective Coping
· Ineffective Role Performance
· Self-Care Deficit
· Chronic Low Self-Esteem
· Disturbed Sleep Pattern
· Impaired Social Interaction
Outcomes for clients with depression relate to how the depression is manifested—for instance, whether or not the person is slow or agitated, sleeps too much or too little, or eats too much or too little. Examples of outcomes for a client with the psychomotor retardation form of depres-sion include the following:
· The client will not injure himself or herself.
· The client will independently carry out activities of daily living (showering, changing clothing, grooming).
· The client will establish a balance of rest, sleep, and activity.
· The client will establish a balance of adequate nutri-tion, hydration, and elimination.
· The client will evaluate self-attributes realistically.
· The client will socialize with staff, peers, and family/ friends.
The client will return to occupation or school activities.
· The client will comply with antidepressant regimen.
· The client will verbalize symptoms of a recurrence.
The first priority is to determine whether a client with depression is suicidal. If a client has suicidal ideation or hears voices commanding him or her to commit suicide, measures to provide a safe environment are necessary. If the client has a suicide plan, the nurse asks additional questions to determine the lethality of the intent and plan. The nurse reports this information to the treatment team. Health care personnel follow hospital or agency policies and procedures for instituting suicide precau-tions (e.g., removal of harmful items, increased supervi-sion).
It is important to have meaningful contact with clients who have depression and to begin a therapeutic relationship regardless of the state of depression. Some clients are quite open in describing their feelings of sadness, hopelessness, helplessness, or agitation. Clients may be unable to sustain a long interaction, so several shorter visits help the nurse to assess status and to establish a therapeutic relationship.
The nurse may find it difficult to interact with these cli-ents because of empathy with such sadness and depression. The nurse also may feel unable to “do anything” for clients with limited responses. Clients with psychomotor retarda-tion (slow speech, slow movement, slow thought processes) are very noncommunicative or may even be mute. The nurse can sit with such clients for a few minutes at intervals throughout the day. The nurse’s presence conveys genuine interest and caring. It is not necessary for the nurse to talk to clients the entire time; rather, silence can convey that cli-ents are worthwhile even if they are not interacting.
“My name is Sheila. I’m your nurse today. I’m going to sit with you for a few minutes. If you need anything, or if you would like to talk, please tell me.”
After time has elapsed, the nurse would say the following:
“I’m going now. I will be back in an hour to see you again.”
It is also important that the nurse avoids being overly cheerful or trying to “cheer up” clients. It is impossible to coax or to humor clients out of their depression. In fact, an overly cheerful approach may make clients feel worse or convey a lack of understanding of their despair.
The ability to perform daily activities is related to the level of psychomotor retardation. To assess ability to perform activities of daily living independently, the nurse first asks the client to perform the global task. For example,
“Martin, it’s time to get dressed.” (global task)
If a client cannot respond to the global request, the nurse breaks the task into smaller segments. Clients with depres-sion can become overwhelmed easily with a task that has several steps. The nurse can use success in small, concrete steps as a basis to increase self-esteem and to build compe-tency for a slightly more complex task the next time.
If clients cannot choose between articles of clothing, the nurse selects the clothing and directs clients to put them on. For example,
“Here are your gray slacks. Put them on.”
This still allows clients to participate in dressing. If this is what clients are capable of doing at this point, this activity will reduce dependence on staff. This request is concrete, and if clients cannot do this, the nurse has infor-mation about the level of psychomotor retardation.
If a client cannot put on slacks, the nurse assists by saying,
“Let me help you with your slacks, Martin.”
The nurse helps clients to dress only when they cannot perform any of the above steps. This allows clients to do as much as possible for themselves and to avoid becoming dependent on the staff. The nurse can carry out this same process with clients when they eat, take a shower, and per-form routine self-care activities.
Because abilities change over time, the nurse must assess them on an ongoing basis. This continual assess-ment takes more time than simply helping clients to dress. Nevertheless, it promotes independence and provides dynamic assessment data about psychomotor abilities.
Often, clients decline to engage in activities because they are too fatigued or have no interest. The nurse can validate these feelings yet still promote participation. For example,
“I know you feel like staying in bed, but it is time to get up for breakfast.”
Often, clients may want to stay in bed until they “feel like getting up” or engaging in activities of daily living. The nurse can let clients know they must become more active to feel better rather than waiting passively for improvement. It may be helpful to avoid asking “yes-or-no” questions. Instead of asking, “Do you want to get up now?” the nurse would say, “It is time to get up now.”
Reestablishing balanced nutrition can be challenging when clients have no appetite or don’t feel like eating. The nurse can explain that beginning to eat helps stimulate appe-tite. Food offered frequently and in small amounts can pre-vent overwhelming clients with a large meal that they feel unable to eat. Sitting quietly with clients during meals can promote eating. Monitoring food and fluid intake may be necessary until clients are consuming adequate amounts.
Promoting sleep may include the short-term use of a sedative or giving medication in the evening if drowsiness or sedation is a side effect. It is also important to encourage clients to remain out of bed and active during the day to facilitate sleeping at night. It is important to monitor the number of hours clients sleep as well as whether they feel refreshed on awakening.
Clients with depression are often overwhelmed by the intensity of their emotions. Talking about these feelings can be beneficial. Initially, the nurse encourages clients to describe in detail how they are feeling. Sharing the burden with another person can provide some relief. At these times, the nurse can listen attentively, encourage clients, and validate the intensity of their experience. For example,
Nurse: “How are you feeling today?” (broadopening)
Client: “I feel so awful . . . terrible.”
Nurse: “Tell me more. What is that like for you?” (using a general lead; encouraging description)
Client: “I don’t feel like myself. I don’t know what to do.”
Nurse: “That must be frightening.” (validating)
It is important at this point that the nurse does not attempt to “fix” the client’s difficulties or offer clichés such as “Things will get better” or “But you know your family really needs you.” Although the nurse may have good intentions, remarks of this type belittle the client’s feelings or make the client feel more guilty and worthless.
As clients begin to improve, the nurse can help them to learn or rediscover more effective coping strategies such as talking to friends, spending leisure time to relax, taking positive steps to deal with stressors, and so forth. Improved coping skills may not prevent depression but may assist cli-ents to deal with the effects of depression more effectively.
The increased activity and improved mood that antidepres-sants produce can provide the energy for suicidal clients to carry out the act. Thus, the nurse must assess suicide risk even when clients are receiving antidepressants. It is also important to ensure that clients ingest the medication and are not saving it in attempt to commit suicide. As clients become ready for discharge, careful assessment of suicide potential is important because they will have a supply of antidepressant medication at home. SSRIs are rarely fatal in overdose, but cyclic and MAOI antidepressants are poten-tially fatal. Prescriptions may need to be limited to only a 1-week supply at a time if concerns linger about overdose.
An important component of client care is management of side effects. The nurse must make careful observations and ask clients pertinent questions to determine how they are tolerating medications. Tables 15.1 through 15.4 give specific interventions to manage side effects of antidepres-sant medications.
Clients and family must learn how to manage the medi-cation regimen because clients may need to take these medications for months, years, or even a lifetime. Educa-tion promotes compliance. Clients must know how often they need to return for monitoring and diagnostic tests.
Teaching clients and family about depression is important. They must understand that depression is an illness, not a lack of willpower or motivation. Learning about the begin-ning symptoms of relapse may assist clients to seek treat-ment early and avoid a lengthy recurrence.
Clients and family should know that treatment out-comes are best when psychotherapy and antidepressants are combined. Psychotherapy helps clients to explore anger, dependence, guilt, hopelessness, helplessness, object loss, interpersonal issues, and irrational beliefs. The goal is to reverse negative views of the future, improve self-image, and help clients gain competence and self-mas-tery. The nurse can help clients to find a therapist through mental health centers in specific communities.
Support group participation also helps some clients and their families. Clients can receive support and encourage-ment from others who struggle with depression, and fam-ily members can offer support to one another. The National Alliance for the Mentally Ill is an organization that can help clients and families connect with local support groups.
Evaluation of the plan of care is based on achievement of individual client outcomes. It is essential that clients feel safe and do not experience uncontrollable urges to commit suicide. Participation in therapy and medication compli-ance produce more favorable outcomes for clients with depression. Being able to identify signs of relapse and to seek treatment immediately can significantly decrease the severity of a depressive episode.