Nursing Interventions ^*denotes collaborative interventions

Rationale

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 suicide. Remain aware of this suicide potential at all times.

Clients with depression may have a potential for suicide that may or may not be expressed and that may change with time.

Observe the client closely, especially under the following circumstances:

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  After antidepressant medication begins to raise the client’s mood.

  
  
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  During unstructured time on the unit or times when the number of staff on the unit is limited.

  
  
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  After any dramatic behavioral change (sudden cheerfulness, relief, or giving away personal belongings).

You must be aware of the client’s activities at all times when there is a potential for suicide or self-injury. Risk of suicide increases as the client’s energy level is increased by medication, when the client’s time is unstructured, and when observation of the client decreases. These changes may indicate that the client has come to a decision to commit suicide.

See Care Plan 26: Suicidal Behavior.

Reorient the client to person, place, and time as indicated (call the client by name, tell the client your name, tell the client where he or she is, etc.).

Repeated presentation of reality is concrete reinforcement for the client.

Spend time with the client.

Your physical presence is reality.

If the client is ruminating, tell him or her that you will talk about reality or about the client’s feelings, but limit the attention given to repeated expressions of rumination.

Minimizing attention may help decrease rumination. Providing reinforcement for reality orientation and expression of feelings will encourage these behaviors.

Initially, assign the same staff members to work with the client whenever possible.

The client’s ability to respond to others may be 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.

When approaching the client, use a moderate, level tone of voice. Avoid being overly cheerful.

Being overly cheerful may indicate to the client that being cheerful is the goal and that other feelings are not acceptable.

Use silence and active listening when interacting with the client. Let the client know that you are concerned and that you consider the client a worthwhile person. See Care Plan 45: Withdrawn Behavior.

The client may not communicate if you are talking too much. Your presence and use of active listening will communicate your interest and concern.

Be comfortable sitting with the client in silence. Let the client know you are available to converse, but do not require the client to talk.

Your silence will convey your expectation that the client will communicate and your acceptance of the client’s difficulty with communication.

When first communicating with the client, use simple, direct sentences; avoid complex sentences or directions.

The client’s ability to perceive and respond to complex stimuli is impaired.

Avoid asking the client many questions, especially questions that require only brief answers.

Asking questions and requiring only brief answers may discourage the client from expressing feelings.

Do not cut off interactions with cheerful remarks or platitudes (e.g., “No one really wants to die,” or “You’ll feel better soon.”). Do not belittle the client’s feelings. Accept the client’s verbalizations of feelings as real, and give support for expressions of emotions, especially those that may be difficult for the client (like anger).

You may be uncomfortable with certain feelings the client expresses. If so, it is important for you to recognize this and discuss it with another staff member rather than directly or indirectly communicating your discomfort to the client. Proclaiming the client’s feelings to be inappropriate or belittling them is detrimental.

Encourage the client to ventilate feelings in whatever way is comfortable—verbal and nonverbal. Let the client know you will listen and accept what is being expressed.

Expressing feelings may help relieve despair, hopelessness, and so forth. Feelings are not inherently good or bad. You must remain nonjudgmental about the client’s feelings and express this to the client.

Allow (and encourage) the client to cry. Stay with and support the client if he or she desires. Provide privacy if the client desires and it is safe to do so.

Crying is a healthy way of expressing feelings of sadness, hopelessness, and despair. The client may not feel comfortable crying and may need encouragement or privacy.

Interact with the client on topics with which he or she is comfortable. Do not probe for information.

Probing or topics that are uncomfortable for the client may be threatening and discourage communication. After trust has been established, the client may be able to discuss more difficult topics.

Talk with the client about coping strategies he or she has used in the past. Explore which strategies have been successful and which may have led to negative consequences.

The client may have had success using coping strategies in the past but may have lost confidence in himself or herself or in his or her ability to cope 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 and stress management skills, such as increasing physical exercise, expressing feelings verbally or in a journal, or meditation techniques. Encourage the client to practice this type of technique while in the hospital.

The client may have limited or no knowledge of stress management techniques or may not have used positive techniques in the past. If the client tries to build skills in the treatment setting, he or she can experience success and receive positive feedback for his or her efforts.

Teach the client about the problem-solving process: explore possible options, examine the consequences of each alternative, select and implement an alternative, and evaluate the results.

The client may be unaware of a systematic method for solving problems. Successful use of the problem-solving process facilitates the client’s confidence in the use of coping skills.

Provide positive feedback at each step of the process. If the client is not satisfied with the chosen alternative, assist the client to select another alternative.

Positive feedback at each step will give the client many opportunities for success, encourage him or her to persist in problem-solving, and enhance confidence. The client also can learn to “survive” making a mistake.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Initially, interact with the client on a one-to-one basis. Manage nursing assignments so that the client interacts with a variety of staff members, as the client tolerates.

Your social behavior provides a role model for the client. Interacting with different staff members allows the client to experience success in interactions within the safety of the staff-client relationship.

Introduce the client to other clients in the milieu and facilitate their interactions on a one client to one client basis. Gradually facilitate social interactions between the client and small groups, then larger groups.

Gradually increasing the scope of the client’s social interactions will help the client build confidence in social skills.

Talk with the client about his or her interactions and observations of interpersonal dynamics.

Awareness of interpersonal and group dynamics is 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 another person for an interaction, appropriate conversation topics, and active listening. Encourage him or her to practice these skills with staff members and other clients, and give the client feedback regarding interactions.

The client may lack social skills and confidence in social interactions; this may contribute to the client’s depression and social isolation.

Encourage the client to identify relationships, social, or recreational situations that have been positive in the past.

The client may have been depressed and withdrawn for some time and have lost interest in people or activities that provided pleasure in the past.

^*Encourage the client to pursue past relationships, personal interests, hobbies, or recreational activities that were positive in the past or that may appeal to the client. Consultation with a recreational therapist may be indicated.

The client may be reluctant to reach out to someone with whom he or she has had limited contact recently and may benefit from encouragement or facilitation. Recreational activities can serve as a structure for the client to build social interactions as well as provide enjoyment.

^*Encourage client to identify supportive people outside the hospital and to develop these relationships.

In addition to re-establishing past relationships or in their absence, increasing the client’s support system by establishing new relationships may help decrease future depressive behavior and social isolation.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Closely observe the client’s food and fluid intake. Record intake, output, and daily weight if necessary.

The client may not be aware of or interested in meeting physical needs, but these needs must be met.

Offer the client foods that are easily chewed, fortified liquids such as nutritional supplements, and high-protein malts.

If the client lacks interest in eating, highly nutritious foods that require little effort to eat may help meet nutritional needs.

Try to find out what foods the client likes, including culturally based or foods from family members, and make them available at meals and for snacks.

The client may be more apt to eat foods he or she likes or has been accustomed to eating.

Do not tell the client that he or she will get sick or die from not eating or drinking.

The client may hope to become ill or die from not eating or drinking.

If the client is overeating, limit access to food, schedule meals and snacks, and serve limited portions. Give the client positive feedback for adhering to the prescribed diet.

The client may need limits to maintain a healthful diet.

Observe and record the client’s pattern of bowel elimination.

Severe constipation may result from the 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 need to offer medication to the client.

The client may be unaware of constipation and may not ask for medication.

Provide the client with his or her own clothing and personal grooming items when possible.

Familiar items will decrease the client’s confusion and promote task completion.

Initiate dressing and grooming tasks in the morning.

Clients with depression may have the most energy and feel best in the morning and may have greater success at that time.

Maintain a routine for dressing, grooming, and hygiene.

A routine eliminates needless decision making, such as whether or not to dress or perform personal hygiene.

The client may need physical assistance to get up, dress, and spend time on the unit.

The client’s ability to arise, initiate activity, and join in the milieu is impaired.

Be gentle but firm in setting limits regarding time spent in bed. Set specific times when the client must be up in the morning, and when and for how long the client may rest.

Specific limits let the client know what is expected and indicate genuine caring and concern for the client.

Provide a quiet, peaceful time for resting. Decrease environmental stimuli (conversation, lights) in the evening.

Limiting noise and other stimuli will encourage rest and sleep.

Provide a nighttime routine or comfort measures (back rub, tepid bath, warm milk) just before bedtime.

Use of a routine may help the client expect to sleep.

Talk with the client for only brief periods during night hours to help alleviate anxiety and to provide reassurance before the client returns to bed.

Talking with the client for long periods during the night will stimulate the client, give the client attention for not sleeping, and interfere with the client’s sleep.

Do not allow the client to sleep for long periods during the day.

Sleeping excessively during the day may decrease the client’s need for and ability to sleep at night.

Use PRN medications as indicated to facilitate sleep. Note: Some sleep medications may worsen depression or cause agitation.

Medications may be helpful in facilitating sleep.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Encourage the client to become involved with staff and other clients in the milieu through interactions and activities.

When the client can focus on other people or interactions, cyclic, negative thoughts are interrupted.

Give the client positive feedback for completing responsibilities and interacting with others.

Positive feedback increases the likelihood that the 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 conversations, it may help to structure the content of interactions, for example, by making an agreement to listen to 10 minutes of “negative” interaction, after which the client will interact on a positive topic.

The client will feel you are acknowledging his or her feelings yet will begin practicing the conscious interruption of negativistic thought and feeling patterns.

Explore with the client his or her personal strengths. Making a written list is sometimes helpful.

While you can help the client discover his or her strengths, it will not be useful for you to list the 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 recreational as a break from self-examination.

The client needs to experience pleasurable 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 accomplished easily and quickly. Begin with a solitary project; progress to group occupational and recreational therapy sessions. Give the client positive feedback for participation.

The client may be limited in his or her ability to deal with complex tasks or stimuli. Any task that the client is able to complete provides an opportunity for positive feedback to the client.

It may be necessary to stress to the client that he or she should begin doing things to feel better, rather than waiting to feel better before doing things.

The client will have the opportunity to recognize his or her own achievements and will receive positive feedback. Without this stimulus, the client may lack motivation to attempt activities.

Give the client honest praise for accomplishing small responsibilities by acknowledging how difficult it can be for the client to perform these tasks.

Clients with low self-esteem do not benefit from flattery or undue praise. Positive feedback provides reinforcement for the client’s growth and can enhance self-esteem.

Gradually increase the number and complexity of activities expected of the client; give positive feedback at each level of accomplishment.

As the client’s abilities increase, he or she can accomplish more complex activities and receive more feedback.