Depression is a mood disorder characterized by intense and persistent feelings of sadness and a loss of interest or enjoyment in things once loved (anhedonia). The clinical diagnosis per the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) is Major depressive disorder (MDD) and includes feelings of worthlessness, a lack of energy, decreased concentration, and suicidal thoughts.
Major depression affects not only the emotional aspect of one’s life but the physical as well. Patients may stop caring for their hygiene, experience insomnia or sleep too much, overeat, or experience a loss of appetite, leading to weight loss or gain.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Hopelessness
- Risk for Self-Mutilation
- Risk for Suicide
- Self-Care Deficit
Nursing Process
Nurses may encounter patients experiencing MDD or other mental health conditions as a comorbidity exacerbated by a medical condition such as chronic pain, cancer, or a terminal illness. Major depression requires the diagnosis and treatment of trained mental health providers, but nurses are vital in creating a therapeutic relationship that allows patients to express their thoughts and feelings while supporting them holistically and maintaining their safety.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to depression.
Review of Health History
1. Note mood alterations or changes in emotion.
Patients with MDD may present with feelings or emotions such as:
- Sadness
- Hopelessness
- Worthlessness
- Emptiness
- Tearfulness
- Anger
- Guilt
- Irritability
2. Inquire about the patient’s activities.
Let the patient describe their daily activities and routines. MDD is severe enough to interfere with the patient’s social life or occupation. Patients may report the following:
- Feeling less motivated
- Decreased energy
- Trouble focusing
- Losing interest in activities once enjoyed (anhedonia)
3. Note fatigue or sleep disturbances.
The patient may reveal fatigue, a lack of energy, and sleep disturbances that include insomnia or sleeping more than usual. The patient may even report slowed thinking or feeling sluggish.
4. Ask about the patient’s appetite and food intake.
Common symptoms of MDD include changes in appetite and weight. This can consist of overeating or not eating enough, causing subsequent weight gain or loss.
5. Review the patient’s family history.
Depression carries a genetic component. Assess for a family history of depression and other mental health disorders.
6. Assess for other mental health conditions.
Patients with depression often have comorbid mental health disorders such as anxiety, panic disorder, obsessive-compulsive disorder, and substance use disorders.
7. Consider the patient’s medical history.
Chronic or terminal medical conditions often contribute to the development of major depression. Assess for chronic pain, cancer, heart disease, stroke, or other life-limiting conditions that may affect the patient’s mental health.
8. Assess for a history of abuse or stressful events.
Childhood abuse is a significant risk factor for depression later in life. Stressful life events such as the death of a loved one, divorce, or financial issues can trigger depression. Unprocessed grief can lead to major depression.
9. Assess the patient’s support system.
Social isolation is a contributing factor for MDD. Patients who lack close relationships or are separated, divorced, or widowed are most likely to experience MDD.
10. Review the patient’s medication and substance use.
Some medications may carry a risk for depression as a side effect. Patients who abuse illegal substances or alcohol increase their risk for major depression.
11. Assess for thoughts of suicide.
MDD is the most prevalent psychiatric diagnosis among suicide victims. The nurse should assess for suicidal ideation. Patients may also participate in self-harming behaviors that the nurse can also monitor for.
Physical Assessment
1. Perform a physical assessment.
A thorough physical assessment, including a neurological exam, is necessary to rule out underlying medical conditions that may be causing depression.
2. Obtain the patient’s weight.
Significant weight gain or loss should be investigated further if unrelated to a medical condition.
3. Observe for clues indicating depression.
Note the patient’s appearance, affect, speech, gestures, and behaviors. A patient exhibiting a depressed mood may appear withdrawn, tearful, disheveled, slow to speak, and lack eye contact.
4. Assess for signs of self-harm.
Patients with MDD may self-harm as a method to cope with feelings of worthlessness, anger, or sadness. Note cuts or burn marks to the extremities. Patients may attempt to hide injuries under bracelets, long sleeves, or pants.
5. Note physical discomfort.
Patients with MDD may experience physical pain due to emotional turmoil and stress. This can manifest as headaches, muscle aches, or generalized pain.
Diagnostic Procedures
1. Assess for underlying medical causes.
No laboratory test can directly diagnose depression. However, the following laboratory tests can rule out medical conditions contributing to symptoms of depression:
- Complete blood account with differential
- Comprehensive metabolic panel
- Thyroid-stimulating hormone
- Free T4
- Vitamin D
- Urinalysis
- Toxicology screening
2. Assist with diagnosis based on assessment tools.
Questionnaires aid in the diagnosis of MDD. The following are common tools used based on various settings:
- Patient Health Questionnaire-9 (PHQ-9)
- Hamilton Rating Scale for Depression (HAM-D)
- Montgomery-Asberg Depression Rating Scale (MADRS)
- Beck Depression Inventory (BDI)
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions related to depression.
1. Administer medications as ordered.
Depression may occur due to abnormalities in neurotransmitters (serotonin, norepinephrine, dopamine), which is why antidepressants are effective in treating these imbalances. Medications may include:
- Selective serotonin reuptake inhibitors (SSRIs)
- Serotonin-norepinephrine reuptake inhibitors (SNRIs)
- Atypical antidepressants
- Tricyclic antidepressants
- Monoamine oxidase inhibitors (MAOIs) (only used when other medications are ineffective)
Other drugs may be used in combination to treat co-occurring mental health conditions and may enhance the effects of antidepressants. These include:
- Mood stabilizers
- Antipsychotics
- Benzodiazepines
- Stimulants
2. Educate on medication adherence.
Antidepressants require a few weeks or more to take effect. Abrupt medication cessation can cause withdrawal and worsening of depression.
3. Monitor for an increased risk of suicide.
Children, adolescents, and young adults are at an increased risk for suicide when starting an antidepressant. Educate parents and patients to monitor for worsening signs of depression and to seek immediate help if experiencing thoughts of suicide.
4. Initiate psychotherapy.
Refer the patient to a mental health professional for psychotherapy, also known as talk therapy. Cognitive behavioral therapy and interpersonal therapy are two types of psychotherapy that are effective in treating MDD.
5. Consider stimulation therapies.
Stimulation therapies treat severe depression that has not improved with medication. It involves emitting a mild electric current to specific areas of the brain involved in mood regulation. Stimulation therapies include:
- Transcranial magnetic stimulation (TMS)
- Vagus nerve stimulation (VNS)
- Electroconvulsive therapy (ECT)
6. Educate the patient and their family about the treatment plan.
Emphasize the need to continue medications even if the patient begins to feel better. Involve family members as applicable to ensure adherence to therapy or other treatment methods.
7. Treat any substance abuse simultaneously with MDD.
Alcohol or drug use can mask symptoms of depression short-term but actually make MDD worse. Substance abuse can be treated concurrently through medications and psychotherapy so the patient learns healthier coping methods.
8. Advise on lifestyle changes.
The nurse can discuss changes the patient can make to support a healthier mind and body. This includes exercise, time outdoors, adequate sleep, and healthy eating.
9. Discuss alternative medicine approaches.
If the patient appears interested in alternative or nonconventional approaches to managing their depression, offer education and resources. Emphasize that these methods alone are usually not enough to treat MDD but can be beneficial alongside conventional medicine. Holistic techniques may include:
- Massage
- Acupuncture
- Yoga
- Supplements
10. Ensure support and offer resources.
It’s important that the patient doesn’t feel isolated. Identify friends, family, religious groups, and support groups the patient can rely on when needed. Encourage journaling or reading self-help books to learn more about depression and navigating difficult emotions.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for major depression, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for depression.
Fatigue
Fatigue is a common symptom expressed by patients with major depression. Patients may also report sleeping difficulties, which can worsen feelings of fatigue.
Nursing Diagnosis: Fatigue
Related to:
- Insomnia
- Depressive symptoms
- Anxiety
- Stressors
- Malnutrition
As evidenced by:
- Altered concentration
- Difficulty maintaining usual routine
- Drowsiness
- Sleeping more than usual
- Nonrestorative sleep pattern
- Expresses a lack of energy
- Expresses tiredness
- Lethargy
Expected outcomes:
- Patient will report the ability to perform mental and physical tasks without feeling overly tired.
- Patient will report increased energy.
- Patient will report an appropriate sleeping schedule.
Assessment:
1. Assess the severity of the patient’s fatigue.
Patients with major depression may express a sense of fatigue that interferes with their ability to complete ADLs, make decisions, or complete daily tasks.
2. Assess possible factors that contribute to the patient’s fatigue.
Fatigue can be caused by depression itself but may also be exacerbated by stress, lack of sleep, lack of exercise, malnutrition, and underlying health conditions.
Interventions:
1. Encourage the patient to establish a sleep routine.
Getting adequate sleep while not oversleeping can be difficult with major depression. Attempt to create a sleep routine by allowing optimal exposure to sunlight during the daytime, limiting naps, and creating an environment conducive to sleep at night.
2. Manage stress effectively.
If the patient is feeling overwhelmed with stress, anxiety, or sadness that is eating their energy, incorporate breathing techniques, guided meditation, or spending time outdoors to reinvigorate their sense of well-being.
3. Set small achievable daily goals.
Major depressive disorder can make even simple tasks like showering or doing the dishes seem monumental. Help the patient set goals and priorities when their energy is limited, such as getting dressed for the day or taking the dog for a walk.
4. Encourage the patient to exercise as appropriate.
Exercise can help promote energy, boost endorphins, and increase mental clarity in patients diagnosed with major depression.
Hopelessness
A patient with major depression may feel no sense of purpose and no way out of their pessimistic state of mind.
Nursing Diagnosis: Hopelessness
Related to:
- Social Isolation
- Long-term stress
- Loss of spiritual beliefs
- Depressed cognitive functions (thinking, decision making)
As evidenced by:
- Verbalized belief that nothing can be changed and no reason to do so
- Passivity
- No response to positive or negative stimuli
- Decreased affect
- Lack of initiative
- Loss of interest in life
- Increased or decreased sleep
- Sighing, not making eye contact, no verbalization
- Substance abuse
- Self-harm
- Suicidal ideation
Expected outcomes:
- Patient will verbalize their feelings regarding hopelessness.
- Patient will identify coping mechanisms to improve feelings of hopelessness.
- Patient will set short and long-term goals to develop and maintain a positive outlook.
Assessment:
1. Assess additional causes beyond depression.
Depression compounded by job loss, relationship strains, legal concerns, financial stress, and other chronic health conditions can worsen hopelessness and may require their own specific interventions.
2. Assess for negative coping mechanisms.
These can include increasing sleep, drug use, risky sexual behaviors, avoiding responsibility, self-sabotaging progress, and self-harm.
3. Determine spiritual beliefs.
Determine if the patient has a strong sense of spirituality and if it has recently changed or become a source of hopelessness. Religious beliefs can be a source of hope but also cause added stress and inadvertently harm the patient’s mental health.
Interventions:
1. Build a trusting relationship.
A trusting, supportive rapport will allow the patient a safe space to address their thoughts and feelings.
2. Help the patient recognize their control.
The patient may have a skewed understanding of what is or isn’t in their control. Help the patient recognize misconceptions and accept only what is within their ability to change.
3. Encourage counseling/therapy.
Major depression requires the interventions of a trained mental health professional. Psychologists can help with acceptance and adaption to life changes, help set realistic goals, and help develop skills to cope.
4. Help identify positive coping behaviors.
Assist the patient in identifying coping behaviors they have used in the past that were effective or activities they once enjoyed that can help now. Examples include journaling, music, dance, sports, traveling, spending time outside, or playing with a pet.
Risk for Self-Mutilation
Patients with major depression participate in self-mutilating behaviors to feel more in control over stressful situations and to cope with emotional pain.
Nursing Diagnosis: Risk for Self-Mutilation
Related to:
- Disturbed interpersonal relationships
- Inability to express tension verbally
- Ineffective coping strategies
- Isolation
- Irresistible urge to cut self
- Low self-esteem
- Negative feelings
- Substance misuse
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain safe and free from self-injury.
- Patient will demonstrate appropriate ways to cope with negative feelings.
- Patient will identify triggers for self-mutilation.
Assessment:
1. Inquire about the patient’s reason for self-mutilation.
Patients may self-harm for various reasons, and once this information is known, the nurse can develop relevant interventions. Patients with depression may self-harm to:
- Release emotional tension or anxiety
- Punish themselves for perceived faults
- Communicate their distress
- Distract from uncomfortable feelings
- Exert control over their thoughts or a situation
2. Assess for co-occurring conditions.
A history of childhood abuse, substance misuse, or other mental health disorders may increase the risk for self-mutilation.
3. Assess the patient’s coping skills.
Self-harm often serves as a coping mechanism for patients with major depression. Understanding the patient’s coping skills and how they deal with stressors and negative emotions can identify unhealthy coping behaviors and help plan appropriate coping tactics.
Interventions:
1. Attempt to understand how self-harming helps the patient.
The nurse should appear nonjudgmental and attempt to gain insight into what the patient feels or seems to achieve when performing self-harming rituals.
2. Assist the patient in recognizing triggers.
Identifying triggers may help prevent self-harming once the patient is aware of emotions or situations that cause them to self-injure.
3. Assist the patient in practicing positive coping methods.
The nurse can reinforce coping methods learned through cognitive behavioral therapy, which helps the patient develop problem-solving skills and restructure thought patterns.
4. Encourage the patient to engage in alternative activities.
Alternative activities such as exercise, journaling, playing a game, or calling a friend can help distract from the urge to self-mutilate.
Risk for Suicide
Patients with major depression that is not controlled may experience greater feelings of hopelessness which is associated with suicidal thoughts.
Nursing Diagnosis: Risk for Suicide
Related to:
- Feelings of hopelessness
- History of previous suicide attempt
- Stockpiling medications
- Giving away possessions
- Sudden euphoric recovery from major depression
- A change in behavior or attitude
- Threats to kill oneself or a desire to die
- Living alone or lack of a support system
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain safe from suicide or self-injury.
- Patient will identify factors contributing to thoughts of suicide.
- Patient will participate in therapy sessions and willingly attempt to change depression symptoms.
Assessment:
1. Assess for a suicide plan.
A patient should be directly asked if they want to kill themself and if they have a specific plan to do so to determine intent.
2. Note the use of drugs or alcohol.
Assess if a patient is using drugs or alcohol or abusing prescribed medications. Easy access to pain medication, benzodiazepines, and anti-depressants can be dangerous for a suicidal patient.
Interventions:
1. Present a positive attitude.
Structure statements and actions in a positive “can do” way instead of “do not.” An example is “You can go for a walk today” or “You get to see your family tomorrow.”
2. Acknowledge suicide and consequences.
The nurse can acknowledge suicide as an option while also discussing the reality of that option and its consequences. Inquire about how suicide will solve the patient’s problems and offer alternatives.
3. Administer medications.
Medications such as anti-depressants, benzodiazepines, and antipsychotics should be given in a controlled and monitored setting.
4. Promote safety.
If on an inpatient behavioral health unit, the patient may require 1:1 supervision to ensure safety. Items that could be used to harm themselves such as clothing items, cords, and sharp objects should be removed.
5. Continually re-evaluate suicide risk.
Especially after mood changes and at discharge as a patient who is feeling better is at the highest risk for suicide because they may now have the energy to carry out their suicide.
Self-Care Deficit
Major depression can affect the patient’s motivation and energy in completing self-care tasks.
Nursing Diagnosis: Self-Care Deficit
Related to:
- Lack of motivation
- Lack of energy
- Loss of interest
- Insomnia or oversleeping
- Preoccupation with thoughts
- Anxiety
- Severe fatigue
As evidenced by:
- Altered sleep schedules (sleeping very late or not enough)
- Poor appearance, body odor, disheveled clothing
- Weight loss from eating inconsistently
- Cluttered or messy living environment
Expected outcomes:
- Patient will bathe at least every other day and dress in clean clothing daily.
- Patient will drink at least 5 glasses of water and eat 2-3 nutritious meals daily.
- Patient will improve sleep habits by instituting a set bedtime and wake time.
Assessment:
1. Assess barriers to self-care.
Depression itself is a barrier but the nurse can delve further into the causes of the patient’s poor self-care. The patient may lack the energy, time, assistance, or may feel the tasks are unimportant.
2. Assess for a support system.
The patient may not necessarily need physical help with tasks, though that should be assessed as well. A support person can mentally and emotionally encourage the depressed patient to participate in their self-care.
3. Assess medication regimen.
The depressed patient likely takes anti-depressants as well as anti-anxiety and sleep aids. These all have relaxing effects and increase drowsiness. Assess how the patient is taking these medications to ensure they are not over-using.
Interventions:
1. Encourage and coach.
A patient with depression has a slower, clouded thought process and difficulty concentrating. They may need step-by-step guidance to complete even simple tasks.
2. Provide a routine and schedule.
Setting a specific sleep/wake schedule and routine for eating, grooming, and dressing can help motivate the patient.
3. Eat with others.
Encourage the patient to eat with family and friends or other patients if applicable to increase socialization.
4. Provide nutritious snacks, meals, and fluids.
The patient with depression may lack an appetite and the energy to prepare meals. Ensure the patient is drinking plenty of water and provide nutritious snacks such as fruit, nut butters, yogurt, or granola that are easily accessible with minimal preparation.
References
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