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Care Plan 25 Major Depressive Disorder

CARE PLAN 25
Major Depressive Disorder
Nursing Diagnosis

Ineffective Coping
Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or
inability to use available resources.

ASSESSMENT DATA
• Suicidal ideas or behavior
• Slowed mental processes
• Disordered thoughts
• Feelings of despair, hopelessness, and worthlessness
• Guilt
• Anhedonia (inability to experience pleasure)
• Disorientation
• Generalized restlessness or agitation
• Sleep disturbances: early awakening, insomnia, or excessive sleeping
• Anger or hostility (may not be overt)
• Rumination
• Delusions, hallucinations, or other psychotic symptoms
• Diminished interest in sexual activity
• Fear of intensity of feelings
• Anxiety

EXPECTED OUTCOMES
Immediate
The client will
• Be free from self-inflicted harm throughout hospitalization
• Engage in reality-based interactions within 24 hours
• Be oriented to person, place, and time within 48 to 72 hours
• Express anger or hostility outwardly in a safe manner, for example, talking with staff members within
5 to 7 days
Stabilization
The client will
• Express feelings directly with congruent verbal and nonverbal messages
• Be free from psychotic symptoms
• Demonstrate functional level of psychomotor activity

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25 Major Depressive Disorder

Community
The client will
• Demonstrate compliance with and knowledge of medications, if any
• Demonstrate an increased ability to cope with anxiety, stress, or frustration
• Verbalize or demonstrate acceptance of loss or change, if any
• Identify a support system in the community

IMPLEMENTATION

Nursing Interventions Rationale


* denotes collaborative interventions

Provide a safe environment for the client. Physical safety of the client is a priority. Many
common items may be used in a self-destructive
manner.
Continually assess the client’s potential for Clients with depression may have a potential for
suicide. Remain aware of this suicide potential at suicide that may or may not be expressed and that
all times. may change with time.
Observe the client closely, especially under the You must be aware of the client’s activities at all
following circumstances: times when there is a potential for suicide or self-
• After antidepressant medication begins to injury. Risk of suicide increases as the client’s
raise the client’s mood. energy level is increased by medication, when the
client’s time is unstructured, and when observation
• During unstructured time on the unit or times of the client decreases. These changes may
when the number of staff on the unit is indicate that the client has come to a decision to
limited. commit suicide.
• After any dramatic behavioral change (sudden
cheerfulness, relief, or giving away personal
belongings).
See Care Plan 26: Suicidal Behavior.
Reorient the client to person, place, and time as Repeated presentation of reality is concrete
indicated (call the client by name, tell the client reinforcement for the client.
your name, tell the client where he or she is, etc.).
Spend time with the client. Your physical presence is reality.
If the client is ruminating, tell him or her that you Minimizing attention may help decrease
will talk about reality or about the client’s rumination. Providing reinforcement for reality
feelings, but limit the attention given to repeated orientation and expression of feelings will
expressions of rumination. encourage these behaviors.
Initially, assign the same staff members to work The client’s ability to respond to others may be
with the client whenever possible. impaired. Limiting the number of new contacts
initially will facilitate familiarity and trust.
However, the number of people interacting with
the client should increase as soon as possible to
minimize dependency and to facilitate the client’s
abilities to communicate with a variety of people.

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25 Major Depressive Disorder

When approaching the client, use a moderate, Being overly cheerful may indicate to the client
level tone of voice. Avoid being overly cheerful. that being cheerful is the goal and that other
feelings are not acceptable.
Use silence and active listening when interacting The client may not communicate if you are talking
with the client. Let the client know that you are too much. Your presence and use of active
concerned and that you consider the client a listening will communicate your interest and
worthwhile person. See Care Plan 45: Withdrawn concern.
Behavior.
Be comfortable sitting with the client in silence. Your silence will convey your expectation that the
Let the client know you are available to converse, client will communicate and your acceptance of
but do not require the client to talk. the client’s difficulty with communication.
When first communicating with the client, use The client’s ability to perceive and respond to
simple, direct sentences; avoid complex complex stimuli is impaired.
sentences or directions.
Avoid asking the client many questions, Asking questions and requiring only brief answers
especially questions that require only brief may discourage the client from expressing
answers. feelings.
Do not cut off interactions with cheerful remarks You may be uncomfortable with certain feelings
or platitudes (e.g., “No one really wants to die,” the client expresses. If so, it is important for you to
or “You’ll feel better soon.”). Do not belittle the recognize this and discuss it with another staff
client’s feelings. Accept the client’s member rather than directly or indirectly
verbalizations of feelings as real, and give communicating your discomfort to the client.
support for expressions of emotions, especially Proclaiming the client’s feelings to be
those that may be difficult for the client (like inappropriate or belittling them is detrimental.
anger).
Encourage the client to ventilate feelings in Expressing feelings may help relieve despair,
whatever way is comfortable—verbal and hopelessness, and so forth. Feelings are not
nonverbal. Let the client know you will listen and inherently good or bad. You must remain
accept what is being expressed. nonjudgmental about the client’s feelings and
express this to the client.
Allow (and encourage) the client to cry. Stay with Crying is a healthy way of expressing feelings of
and support the client if he or she desires. Provide sadness, hopelessness, and despair. The client may
privacy if the client desires and it is safe to do so. not feel comfortable crying and may need
encouragement or privacy.
Interact with the client on topics with which he or Probing or topics that are uncomfortable for the
she is comfortable. Do not probe for information. client may be threatening and discourage
communication. After trust has been established,
the client may be able to discuss more difficult
topics.

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25 Major Depressive Disorder

Talk with the client about coping strategies he or The client may have had success using coping
she has used in the past. Explore which strategies strategies in the past but may have lost confidence
have been successful and which may have led to in himself or herself or in his or her ability to cope
negative consequences. with stressors and feelings. Some coping strategies
can be self-destructive (e.g., self-medication with
drugs or alcohol).
Teach the client about positive coping strategies The client may have limited or no knowledge of
and stress management skills, such as increasing stress management techniques or may not have
physical exercise, expressing feelings verbally or used positive techniques in the past. If the client
in a journal, or meditation techniques. Encourage tries to build skills in the treatment setting, he or
the client to practice this type of technique while she can experience success and receive positive
in the hospital. feedback for his or her efforts.
Teach the client about the problem-solving The client may be unaware of a systematic method
process: explore possible options, examine the for solving problems. Successful use of the
consequences of each alternative, select and problem-solving process facilitates the client’s
implement an alternative, and evaluate the confidence in the use of coping skills.
results.
Provide positive feedback at each step of the Positive feedback at each step will give the client
process. If the client is not satisfied with the many opportunities for success, encourage him or
chosen alternative, assist the client to select her to persist in problem-solving, and enhance
another alternative. confidence. The client also can learn to “survive”
making a mistake.

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25 Major Depressive Disorder

Nursing Diagnosis

Impaired Social Interaction


Insufficient or excessive quantity or ineffective quality of social exchange.

ASSESSMENT DATA
• Withdrawn behavior
• Verbalization diminished in quantity, quality, or spontaneity
• Rumination
• Low self-esteem
• Unsatisfactory or inadequate interpersonal relationships
• Verbalizing or exhibiting discomfort around others
• Social isolation
• Inadequate social skills
• Poor personal hygiene

EXPECTED OUTCOMES
Immediate
The client will
• Communicate with others, for example, respond verbally to question(s) asked by staff within 24 to 48
hours
• Participate in activities within 48 to 72 hours
Stabilization
The client will
• Initiate interactions with others, for example, approach a staff member to talk at least once per shift
• Assume responsibility for dealing with feelings
Community
The client will
• Re-establish or maintain relationships and a social life
• Establish a support system in the community, for example, initiate contacts with others by telephone

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25 Major Depressive Disorder

IMPLEMENTATION

Nursing Interventions Rationale


* denotes collaborative interventions

Initially, interact with the client on a one-to-one Your social behavior provides a role model for the
basis. Manage nursing assignments so that the client. Interacting with different staff members
client interacts with a variety of staff members, as allows the client to experience success in
the client tolerates. interactions within the safety of the staff–client
relationship.
Introduce the client to other clients in the milieu Gradually increasing the scope of the client’s
and facilitate their interactions on a one client to social interactions will help the client build
one client basis. Gradually facilitate social confidence in social skills.
interactions between the client and small groups,
then larger groups.
Talk with the client about his or her interactions Awareness of interpersonal and group dynamics is
and observations of interpersonal dynamics. an important part of building social skills. Sharing
observations provides an opportunity for the client
to express his or her feelings and receive feedback
about his or her progress.
Teach the client social skills, such as approaching The client may lack social skills and confidence in
another person for an interaction, appropriate social interactions; this may contribute to the
conversation topics, and active listening. client’s depression and social isolation.
Encourage him or her to practice these skills with
staff members and other clients, and give the
client feedback regarding interactions.
Encourage the client to identify relationships, The client may have been depressed and
social, or recreational situations that have been withdrawn for some time and have lost interest in
positive in the past. people or activities that provided pleasure in the
past.
*Encourage the client to pursue past The client may be reluctant to reach out to
relationships, personal interests, hobbies, or someone with whom he or she has had limited
recreational activities that were positive in the contact recently and may benefit from
past or that may appeal to the client. Consultation encouragement or facilitation. Recreational
with a recreational therapist may be indicated. activities can serve as a structure for the client to
build social interactions as well as provide
enjoyment.
*Encourage client to identify supportive people In addition to re-establishing past relationships or
outside the hospital and to develop these in their absence, increasing the client’s support
relationships. system by establishing new relationships may help
decrease future depressive behavior and social
isolation.

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25 Major Depressive Disorder

Nursing Diagnosis

Bathing Self-Care Deficit


Impaired ability to perform or complete bathing activities for self.

Dressing Self-Care Deficit


Impaired ability to perform or complete dressing activities for self.

Feeding Self-Care Deficit


Impaired ability to perform or complete self-feeding activities.

Toileting Self-Care Deficit


Impaired ability to perform or complete toileting activities for self.

ASSESSMENT DATA
• Anergy (overall lack of energy for purposeful activity)
• Decreased motor activity
• Lack of awareness or interest in personal needs
• Self-destructive feelings
• Withdrawn behavior
• Psychological immobility
• Disturbances of appetite or regular eating patterns
• Fatigue

EXPECTED OUTCOMES
Immediate
The client will
• Establish adequate nutrition, hydration, and elimination with nursing assistance within 2 to 4 days
• Establish an adequate balance of rest, sleep, and activity with nursing assistance within 2 to 4 days
• Establish adequate personal hygiene, for example, tolerate bathing and grooming as assisted by staff
within 24 to 48 hours
Stabilization
The client will
• Maintain adequately balanced physiologic functioning
• Maintain adequate personal hygiene independently, for example, follow structured routine for bathing
and hygiene, initiate self-care activities
Community
The client will
• Maintain a daily routine that meets physiologic and personal needs, including nutrition, hydration,
elimination, hygiene, sleep, activity

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25 Major Depressive Disorder

IMPLEMENTATION

Nursing Interventions Rationale


* denotes collaborative interventions

Closely observe the client’s food and fluid intake. The client may not be aware of or interested in
Record intake, output, and daily weight if meeting physical needs, but these needs must be
necessary. met.
Offer the client foods that are easily chewed, If the client lacks interest in eating, highly
fortified liquids such as nutritional supplements, nutritious foods that require little effort to eat may
and high-protein malts. help meet nutritional needs.
Try to find out what foods the client likes, The client may be more apt to eat foods he or she
including culturally based or foods from family likes or has been accustomed to eating.
members, and make them available at meals and
for snacks.
Do not tell the client that he or she will get sick The client may hope to become ill or die from not
or die from not eating or drinking. eating or drinking.
If the client is overeating, limit access to food, The client may need limits to maintain a healthful
schedule meals and snacks, and serve limited diet.
portions. Give the client positive feedback for
adhering to the prescribed diet.
Observe and record the client’s pattern of bowel Severe constipation may result from the
elimination. depression; inadequate exercise, food, or fluid
intake; or the effects of some medications.
Encourage good fluid intake. Constipation may result from inadequate fluid
intake.
Be aware of PRN laxative orders and the possible The client may be unaware of constipation and
need to offer medication to the client. may not ask for medication.
Provide the client with his or her own clothing Familiar items will decrease the client’s confusion
and personal grooming items when possible. and promote task completion.
Initiate dressing and grooming tasks in the Clients with depression may have the most energy
morning. and feel best in the morning and may have greater
success at that time.
Maintain a routine for dressing, grooming, and A routine eliminates needless decision making,
hygiene. such as whether or not to dress or perform
personal hygiene.
The client may need physical assistance to get up, The client’s ability to arise, initiate activity, and
dress, and spend time on the unit. join in the milieu is impaired.
Be gentle but firm in setting limits regarding time Specific limits let the client know what is expected
spent in bed. Set specific times when the client and indicate genuine caring and concern for the
must be up in the morning, and when and for how client.
long the client may rest.

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25 Major Depressive Disorder

Provide a quiet, peaceful time for resting. Limiting noise and other stimuli will encourage
Decrease environmental stimuli (conversation, rest and sleep.
lights) in the evening.
Provide a nighttime routine or comfort measures Use of a routine may help the client expect to
(back rub, tepid bath, warm milk) just before sleep.
bedtime.
Talk with the client for only brief periods during Talking with the client for long periods during the
night hours to help alleviate anxiety and to night will stimulate the client, give the client
provide reassurance before the client returns to attention for not sleeping, and interfere with the
bed. client’s sleep.
Do not allow the client to sleep for long periods Sleeping excessively during the day may decrease
during the day. the client’s need for and ability to sleep at night.
Use PRN medications as indicated to facilitate Medications may be helpful in facilitating sleep.
sleep. Note: Some sleep medications may worsen
depression or cause agitation.

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25 Major Depressive Disorder

Nursing Diagnosis

Chronic Low Self-Esteem


Longstanding negative self-evaluating/feelings about self or self-capabilities.

ASSESSMENT DATA
• Feelings of inferiority
• Defeatist thinking
• Self-criticism
• Lack of involvement
• Minimizing of own strengths
• Guilt
• Feelings of despair, worthlessness

EXPECTED OUTCOMES
Immediate
The client will
• Verbalize increased feelings of self-worth within 2 to 5 days
• Express feelings directly and openly with nursing facilitation within 2 to 4 days
• Evaluate own strengths realistically, for example, describe three areas of personal strength, with
nursing assistance, within 2 to 4 days
Stabilization
The client will
• Demonstrate behavior consistent with increased self-esteem, for example, make eye contact, initiate
conversation or activity with staff or other clients
• Make plans for the future consistent with personal strengths
Community
The client will
• Express satisfaction with self and personal qualities

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25 Major Depressive Disorder

IMPLEMENTATION

Nursing Interventions Rationale


* denotes collaborative interventions

Encourage the client to become involved with When the client can focus on other people or
staff and other clients in the milieu through interactions, cyclic, negative thoughts are
interactions and activities. interrupted.
Give the client positive feedback for completing Positive feedback increases the likelihood that the
responsibilities and interacting with others. client will continue the behavior and begin to
internalize positive feelings, such as the
satisfaction of completing a task successfully.
If negativism dominates the client’s The client will feel you are acknowledging his or
conversations, it may help to structure the content her feelings yet will begin practicing the conscious
of interactions, for example, by making an interruption of negativistic thought and feeling
agreement to listen to 10 minutes of “negative” patterns.
interaction, after which the client will interact on
a positive topic.
Explore with the client his or her personal While you can help the client discover his or her
strengths. Making a written list is sometimes strengths, it will not be useful for you to list the
helpful. client’s strengths. The client needs to identify
them but may benefit from your supportive
expectation that he or she will do so.
Involve the client in activities that are pleasant or The client needs to experience pleasurable
recreational as a break from self-examination. activities that are not related to self and problems.
Such experiences can demonstrate the usefulness
of incorporating leisure activities into his or her
life.
*At first, provide simple activities that can be The client may be limited in his or her ability to
accomplished easily and quickly. Begin with a deal with complex tasks or stimuli. Any task that
solitary project; progress to group occupational the client is able to complete provides an
and recreational therapy sessions. Give the client opportunity for positive feedback to the client.
positive feedback for participation.
It may be necessary to stress to the client that he The client will have the opportunity to recognize
or she should begin doing things to feel better, his or her own achievements and will receive
rather than waiting to feel better before doing positive feedback. Without this stimulus, the client
things. may lack motivation to attempt activities.
Give the client honest praise for accomplishing Clients with low self-esteem do not benefit from
small responsibilities by acknowledging how flattery or undue praise. Positive feedback
difficult it can be for the client to perform these provides reinforcement for the client’s growth and
tasks. can enhance self-esteem.
Gradually increase the number and complexity of As the client’s abilities increase, he or she can
activities expected of the client; give positive accomplish more complex activities and receive
feedback at each level of accomplishment. more feedback.

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.