MAJOR DEPRESSION/DYSTHYMIC DISORDER

DSM-IV
DEPRESSIVE DISORDERS
296.xx Major depressive disorder
296.2x Single episode
296.3x Recurrent
300.4 Dysthymic disorder
311 Depressive disorder NOS

A disturbance of mood, characterized by a full or partial depressive syndrome, or

loss of interest or pleasure in usual activities and pastimes with evidence of
interference in social/occupational functioning.

ETIOLOGICAL THEORIES
Psychodynamics
Psychoanalytical theory focuses on an early unsatisfactory parent/child
relationship, with an unresolved grieving process. This results in the individual
remaining fixed in the anger stage of the grieving process and turning it inward on
the self. The ego remains weak, while the superego expands and becomes punitive.
Cognitive theory projects a belief that depression occurs as a result of impaired
cognition, fostering a negative evaluation of self through disturbed thought
processes. The individual is pessimistic and views self as inadequate and worthless
and life as hopeless.
Learning theorists propose that depressive illness arises out of the individual’s
having experienced numerous failures (either real or perceived). A feeling of
inability to succeed at any endeavor ensues. This “learned helplessness” is viewed
as a predisposition to depressive illness. The behavioral model states that the cause
of depression is in the person-behavior-environment interaction. Although people
are seen as capable of exercising control over their behavior, they are not totally
free of environmental influence.

Biological
A family history of major affective disorders may exist in individuals with
depressive disorders. Recently it has been found that the disease has a genetic
marker, as shown by numerous studies that support the involvement of heredity in
depressive illness.
Biochemical factors (e.g., electrolyte imbalances) appear to play a role in depressive
illness. An error in metabolism results in the transposition of sodium and potassium
within the neuron. Another theory implicates the biogenic amines norepinephrine,
dopamine, and serotonin. The levels of these chemicals are deficient in individuals with
depressive disorders. Controversy remains as to whether these biochemical changes
cause the depression or whether they are caused by the illness. In recent years, a
common form of major depression called seasonal affective disorder (SAD) has been
identified. Recurring each year, starting in fall or winter and ending in spring, the
symptoms are largely typical of depression, with some atypical symptoms (excessive
sleep, increased appetite, and weight gain). This disorder is believed to be caused by the
decreased availability of sunlight and is related to circadian cycles, which are set by each
individual’s internal biological clock. Circadian cycles are more precisely adjusted and
coordinated by the alternation of darkness and light.
 Impaired seratonergic transmission has also been investigated as a cause of
depression (indolamine hypothesis). It has been shown that multiple regions of the
brain in depressed clients lack metabolic responsivity, suggesting a generalized
subresponsivity of the serotonergic system. Additionally, current research suggests
that infection with the Borna disease virus (BDV) may be linked to some cases of
major depression and other severe mood disorders.

Family Dynamics
Object loss theory suggests that depressive illness occurs if the person is
separated from or abandoned by a significant other during the first 6 months of life.
The bonding process is thereby interrupted, and the child withdraws from people
and the environment.

CLIENT ASSESSMENT DATA BASE

Activity/Rest
Fatigue, malaise, decreased energy level, lethargy
Sleep disturbances (e.g., insomnia) occur in 90% of cases—either anxiety insomnia
(with difficulty falling asleep) or depressive insomnia (with early morning
awakening, accompanied by painful ruminations); also hypersomnia (with
restlessness and feeling unrefreshed, particularly in SAD)
May report feeling best early in the morning, then continually feeling worse as the
day progresses (dysthymia); or the opposite may be true (especially in severe
depression)

Ego Integrity
Feelings of worthlessness: self-derogatory statements, expressions of guilt, or
exaggeration of minor inadequacies; may assume delusional proportions with
presentations of unrealistic evidence of self-worth/intense focus on self (e.g.,
feeling oneself responsible for major tragedies and catastrophes or persecuted
for a failure)
Morbid sadness; actual loss or life stressor perceived as a loss (e.g., retirement, job
loss, divorce, illness, aging); may or may not see connection between perceived
losses and onset of depression
Feelings of helplessness, hopelessness, powerlessness, pessimism, irritability,
excessive anger

Elimination
Constipation and urinary retention may be present

Food/Fluid
Decreased/increased appetite accompanied by significant change in weight
(average gain of 10 pounds in SAD)

Hygiene
Inattention to personal care needs, unkempt appearance
Possible body odor
Posture may be bent/slouched (defeated-looking)

Neurosensory
Dejected or sad mood, with loss of interest/enjoyment in usual activities
Depressed mood for most of day, for more days than not, for at least 2 years
(dysthymia), or with intermittent symptom-free periods, for at least 2 months
(recurrent)
Expressed sadness, dejection, not caring about anything, not seeing any future for
self; tending to sigh and be tearful
Irritability, headache
Psychotic features with prominent delusions and/or hallucinations (major
depression)
Psychomotor Retardation: May present either a “slow motion” picture, with
slowed speech and latencies (long pauses before responding), decreased
amount of speech, and slowed body movements; or agitation, featuring
constant, rapid, purposeless movements (severe depression)
Thinking characterized by poor concentration and decreased memory, indecision,
suicidal ideation

Safety
Thoughts of suicide/wanting to die possibly occurring frequently throughout the
illness; may range in severity from indifference about the consequences of
behavior (e.g., lack of cooperation with medical treatment, or dangerous
driving), to wishing it were “over” or for death, to specific suicide plans and
attempts

Sexuality
Disinterest in sexual activities, and/or impotence
Women affected almost twice as often as men, primarily during the childbearing
years of late 20s to early 30s and again in the postmenopausal years of late 40s
to early 50s

Social Interactions
Participation diminished, difficulty starting activities, withdrawal (e.g., housebound
or remains in a single room/bed)

Teaching/Learning
Family history of depression; high rates of alcoholism/other drug abuse

DIAGNOSTIC STUDIES
(The several biochemical alterations in depression are not, by themselves, indicative
of depression but, combined with clinical observation, may indicate best
pharmacological response.)
Thyroid-Stimulating Hormone Response to Thyrotropin-Releasing Hormone:
Decreased level suggests depression.
Dexamethasone-Suppression Test (DST) (an indirect marker of melancholia):
Postdexamethasone cortisol levels exceeding 5 g/dl indicate abnormal/positive
result and can be used to predict effectiveness of antidepressants.
EEG Sleep Profile: This shows reduced latency of rapid eye movement (REM)
sleep.
CBC, Blood Glucose, Electrolytes, Renal/Liver Function Tests: These identify
abnormalities contributing to or resulting from depression.
Other medical tests that may be included:
 Platelet Monoamine Oxidase Activity (MAO): Increased.
Biogenic Amines (Especially Norepinephrine and Serotonin Levels):
Decreased (clients with low serotonin levels are 10 times more likely to commit
suicide within a year).
a-Acid Glycoprotein: Inhibitor of serotonin transporter is elevated.
Urinary 3-Methoxy-4-Hydroxyphenylglycol (MHPG): If low, indicates decreased
norepinephrine output.
Cerebrospinal Fluid Level of 5-Hydroxytryptamine (5HIAA): Reduced.
Minnesota Multiphasic Personality Inventory (MMPI): Scale 2 consistently
elevated.
Wechsler Adult Intelligence Scale-Revised (WAIS-R): Overall performance
score significantly lower than verbal score.
Rorschach Test: Long reaction times, chromatic color responses diminished.
Thematic Apperception Test (TAT): Short, stereotyped responses/simple
descriptions of cards.
Zung (or Similar) Depressive Scale (ADS): Self-report reflecting affective,
psychic, somatic characteristics of depression.

NURSING PRIORITIES
1. Promote physical safety with special focus on suicide prevention.
2. Provide for client’s basic needs, promoting highest possible level of independent
functioning.
3. Provide experience/interactions that enhance self-esteem, sense of personal
power.
4. Support client/family participation in follow-up care/community treatment.
5. Provide information about condition, prognosis, and treatment needs.

DISCHARGE GOALS
1. Suicidal ideation/self-violent behaviors absent.
2. Physiological stability achieved with responsibility for self demonstrated.
3. Client expressing feelings appropriately with some optimism and hope for the
future.
4. Client/family participating in follow-up care/community treatment.
5. Condition, prognosis, and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.

NURSING DIAGNOSIS VIOLENCE, risk for self-directed

Risk Factors May Include: Depressed mood
Feelings of worthlessness and hopelessness
[Possible Indicators:] Verbalization of suicidal ideation/plan or futility
of trying (e.g., “What’s the use?”)
Giving possessions away/making a will
Sudden mood elevation/appearing more
energized or displaying calmer, more peaceful
manner
Refusal/reluctance to sign a “no harm” contract
 Desired Outcomes/Evaluation Criteria— Voluntarily comply with suicide precautions, sign
Client Will: “no harm” contract.
Verbalize a decrease/absence of suicidal ideas.
State 2 reasons for not harming self.
Commit no acts of self-violence.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Identify degree of risk/potential for suicide through Degree of hopelessness expressed by
client is
direct questions (e.g., “Have you thought about important indicator of severity of depression and
killing yourself?”). Assess seriousness of suicidal suicide risk. Eight of 10 clients who state an
tendency, noting behaviors such as gestures, threats, intention to commit suicide do so. The
more
giving away possessions, previous attempts, thought-out the plan, the higher the chances of
presence of hallucinations or delusions. (Use scale completing it. The chances of suicide
increase if
of 1–10 and prioritize care according to severity of there was a previous suicide attempt or if
a family
threat, availability of means.) history of suicide and depression is present.
Impulsive clients are more likely to attempt
suicide without giving clues, including those with

psychotic thinking who are especially at risk

when
hallucinations or delusions encourage self-harm.
Note: Individuals with untreated depression
have
a suicide rate of 15%.
Reevaluate potential for suicide periodically at key Suicide risk is the greatest during the first
few
times (e.g., during mood changes, at initiation of/weeks following admission to treatment. More
changes in medication regimen, when increasing than half of suicides by hospitalized clients occur

withdrawal occurs, when discharge planning out of the hospital, while they are on leave or
becomes active, before sending out on pass, before during an unauthorized absence. The
highest risk
discharge from program). is when the client has both suicidal ideation and
sufficient energy with which to act (e.g., at the
point when the client begins to feel better).
Implement suicide precautions. For example, Communicates caring and provides sense of
explain to client that you are concerned for his or protection.
her safety and that you will be helping client to stay
“safe.”
Create a time-specific contract with client on what Documents actions taken to prevent
suicide and
client and nurse will do to provide for client’s safety. client response. It also promotes
communication
Renew contract as appropriate. Place a copy of the and can help client realize that others
care what
“contract,” signed by client and staff, in the chart/ happens. Short-term contracts encourage
client to
file and give a copy to the client to keep. deal with the here-and-now and provide
opportunity to reassess situation.
When hospitalized:
Provide close observation (1:1 or random checks Being alert for suicidal and escape attempts
every 10 to 15 minutes for most acute risk). Place in facilitates being able to prevent or
interrupt
room close to nurse’s station; do not assign to a harmful behavior.
single room. Accompany to off-ward activities if
attendance is indicated. Ask client to stay in view
of staff member at all times.
Be alert to use of hazardous equipment; remove Provides environmental safety; removes objects
hazardous personal items (e.g., scarves, belts, razor that may prompt suicidal
thoughts/attempts.
blades, scissors).
Check all items brought in to or by the client as Suicidal clients may bring harmful items back
indicated. Ask family and other visitors to avoid from a pass or may ask family for items, with a
bringing hazardous items. suicide plan in mind.
Maintain special care in administration of Prevents the client from saving medication up to
medications. overdose or discarding and not taking
medication.
Be alert when client is using bathroom. Although decreasing the client’s privacy may
seem
awkward, it is essential that the suicidal client be

within caregiver’s view at all times to prevent

self-harm (e.g., hanging).
Make rounds at frequent, irregular intervals Prevents staff surveillance from becoming
(especially at night, toward early morning, at predictable. To be aware of client’s location is
change of shift, or other predictably busy times for important, especially when staff is busy
and least
staff). available/observant.
Routinely check environment for hazards. ProvideMinimizing opportunities for self-harm is an
for environmental safety (e.g., lock doors/windows ongoing issue requiring constant attention
and
when not supervised; block access to stairways, consideration of the unusual.
roof, and construction areas; monitor cleaning
chemicals/repair supplies).
Review medical regimen, including electro- Antidepressant drugs may take 3 or more weeks
to
convulsive therapy (ECT), allowing client/family lift mood. In the meantime, other forms of
therapy
to ask questions and express feelings freely. may be required to provide protection for the
suicidal client. ECT is generally a second line of
treatment, used if depression has not responded
to
pharmacological treatment and/or client
continues
to display suicidal ideation, sleeplessness,
refusal
to eat and drink. Client may fear ECT, and nurse
needs to empathize with client’s fears while
supporting ECT as being a positive treatment
alternative.
Be aware of staff attitudes toward the use of ECT,When nurses/others have negative or ambivalent

and avoid influencing client negatively. feelings toward this treatment, these feelings
can
be communicated to the client, causing
confusion/reluctance to accept appropriate
therapy.

Collaborative
Administer medications as indicated, e.g.: SSRIs: Selective serotonic reuptake inhibitors and cyclic
fluoxetine (Prozac), fluvoxamine (Luvox), antidepressants are generally considered the
safest
paroxetine (Paxil), sertraline (Zoloft); tricyclics, and easiest to manage of the antidepressants
and
e.g., amitriptyline (Elavil), desipramine (Norpramin), so are started first. If response is not
noted in 4 to 6
doxepin (Sinequan), imipramine (Tofranil); weeks, an MAOI may be the drug of choice.
These
heterocyclics, e.g., amoxapine (Asendin), bupropion drugs act by blocking enzyme
degradation of
(Wellbutrin), maprotiline (Ludiomil), trazodone neurotransmitters (norepinephrine, serotonin).
(Desyrel); monoamine oxidase inhibitors (MAOIs),Note: Medications inhibiting reuptake of
e.g., phenelzine (Nardil), isocarboxazid (Marplan), serotonin, or heterocyclic drugs (e.g.,
Wellbutrin),
tranylcypromine (Parnate). are usually preferred for treating depression in
bipolar disorders, whereas tricyclics and MAOIs
may increase possibility of switch to manic
behavior. (Tricyclics use a “shotgun approach,”
whereas newer generations of drugs usually
target a specific neurotransmitter. TCAs also can
cause toxicity before therapeutic levels are
achieved, and MAOIs can cause fatal central
serotonin syndrome if administered within 2
weeks of SSRI therapy).
Evaluate cardiac status, obtain ECG as appropriate. TCAs can increase cardiac conduction
disturbances and cause dangerous interaction
with
antidysrhythmic medications.
Prepare for/assist with ECT as indicated. ECT becomes essential and in some cases life
saving when depression does not respond to
other
treatments and suicide is a major risk. (Of clients

with major depression, 80% to 90% show marked

improvement after ECT.)

NURSING DIAGNOSIS GRIEVING, dysfunctional

May Be Related to: Multiple life changes, actual/perceived loss
including loss of physiopsychosocial well-being
(poor nutrition, little or no exercise)
Thwarted grieving response to a loss, lack of
resolution of previous grieving response
Absence of anticipatory grieving
Possibly Evidenced by: Perception of areas in life as unfulfilled or as
losses; denial of loss; expression of unresolved
issues, guilt
Crying/labile affect
Interference with life functioning, alterations in
concentration/pursuit of tasks, changes in eating
habits, sleep/dream patterns, activity level, libido
Desired Outcomes/Evaluation Criteria— Demonstrate progress in dealing with stages of
Client Will: grief at own pace.
Participate in work/self-care activities at level of
ability.
Verbalize a sense of progress toward resolution
of the grief and hope for the future.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Assess losses that have occurred in the client’s life. Denial of the impact/importance of a loss
may be
Discuss meaning these have had for the client. contributing to severity of depression.
Determine cultural factors and ways individual has Cultural beliefs affect how people express
and
dealt with previous loss(es). accept grieving processes.
Encourage verbalization of and assist in Verbalization of feelings in a nonthreatening
identification of feelings and relationship between environment can help client begin to deal
with
feelings and event/stressor, when the event is unrecognized/unresolved issues that may be
known. contributing to depression. Helps client realize
response (feeling) is connected to the stressor or
precipitating event.
Discuss ways to identify and cope with underlying Begins to increase the client’s repertoire
of coping
feelings (e.g., hurt, rejection, anger). Set limits strategies. Learning that choices are available for

regarding destructive behavior. behaving differently can often decrease the

feeling
of being stuck. “Storytelling” of how others have

handled situations may be helpful, not only in

providing potential solutions but also in giving
the
idea that the problem is manageable.
Identify normal stages of grief and acknowledge Helps client understand normalcy of feelings and

reality of associated feelings, e.g., guilt, anger, may alleviate some of the guilt generated by
these
powerlessness. feelings.
Assist client to identify need to address problem Contracting for change begins with agreeing on
differently. Describe all aspects of the problem “the problem.” It helps the client to consider all
through the use of therapeutic communication skills. aspects of the problem, to define clearly
what the
client is dealing with.
Help client recognize early symptoms of depression Involves the client actively, reducing
sense of
and plan ways to alleviate them. Help client powerlessness. Rehearsal promotes
generalization
formulate steps to take for outside support if of recently learned coping strategies to new
symptoms continue. situations and may help to minimize recurrence
of
depressive feelings.
Reinforce the positive aspects of being able to reach Encourages the client to learn how to
manage/take
out for help. care of self. It is important that the client has
support available should help be needed and
that the client experience needing to reach out
as
positive, reflecting sense of empowerment and
own self-worth.

NURSING DIAGNOSIS ANXIETY [moderate to severe]/THOUGHT

PROCESSES, altered
May Be Related to: Psychological conflicts; unconscious conflict
about essential values/goals of life
Unmet needs
Threat to self-concept
 Sleep deprivation
Interpersonal transmission/contagion
Possibly Evidenced by: Reports of nervousness or fearfulness, feelings of
inadequacy
Agitation, angry or tearful outbursts, rambling
and discoordinated speech
Restlessness, hand-rubbing or -wringing,
tremulousness
Poor memory and concentration, decreased
ability to grasp ideas, inability to follow, impaired
ability to make decisions, circumstantiality
(unable to get to the point)
Numerous, repetitious physical complaints
without organic cause
Ideas of reference, hallucinations/delusions
Desired Outcomes/Evaluation Criteria— Verbalize awareness of feelings of anxiety,
Client Will: changes in thinking/behavior.
Identify ways to deal effectively with decision-
making.
Converse appropriately with staff or in groups.
Attend to and complete tasks (ADLs,
occupational therapy projects, etc.) of increasing
length and difficulty.
Report anxiety is reduced to manageable level.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Evaluate/reevaluate level of anxiety. Approaches differ, depending on level of anxiety.

(Refer to CP: Generalized Anxiety Disorder.)

Recognize and deal with own feelings in response Anxiety is highly communicable. If the
nurse
to client’s anxiety. becomes anxious (or impatient, irritable, etc.),
this
will be communicated and feed client’s anxiety.
Listen nonjudgmentally to client’s expressions; Helps client identify basis for anxious feelings,
convey empathy; acknowledge or label feelings for communicates acceptance, and assists in
reducing
client. current level of anxiety.
Use short, concrete communication. Assume calm, Attention, concentration, and problem-
solving are
“in-control-of-things” manner. Let client know compromised by anxiety. Benign attention/
about safety and supportive attentions of the staff/ monitoring by staff may be interpreted in
a
facility. paranoid manner by the client.
Decrease environmental stimulation; remove to Reduces anxiety-provoking stimuli and
quiet area away from other clients. Suggest activity distractions. Helps client refocus away
from
that may be relaxing (e.g., warm bath, back rub). anxiety.
Involve in a quiet activity when calmer.
Maintain a calm attitude and use physical touch, if May prove helpful if anxiety stems from
acceptable to client. delusions/hallucinations; touch can restore client

to reality. Caution is required with suspicious

clients who may interpret touch as aggression.
Defer problem-solving, assessment of precipitating Ability to problem-solve is compromised,
and
factors until anxiety is reduced to a more such requests may increase anxiety.
manageable level.
Analyze incident with client and staff to identify Develops an individualized plan that will help
precipitating factors, early signs of building anxiety, decrease anxiety;
establishes/reestablishes
previously helpful interventions. previous coping skill. Client needs to learn how
to
manage own anxiety by recognizing the signs
and
then acting to lower the anxiety.
Stay with client as indicated. Promotes sense of safety and provides
opportunity
to focus on present and use techniques to
alleviate
anxious feelings.
Decrease decision-making for client by offering a Decreasing options lessens the amount of
choice between only 2 options (e.g., whether to information to process and enhances decision-
have cereal or eggs, rather than a full menu). making. As ability to think through incoming
information increases, more options can be
added.
Choose for the client when necessary, based on Judicious choosing for the client may decrease
knowledge of the client’s interest and activity level, sense of inadequacy when client feels
telling client how the choice was decided. overwhelmed and may provide role-modeling of
decision-making process.
Discourage use of caffeine. Can produce anxiety-like symptoms,
compounding clinical picture and client’s
perception of situation.
Assist client to learn relaxation/imagery exercises. Develops skills for coping with anxiety
responses.
Use tapes of relaxation exercises and calm music.
Prompt client to use these techniques when
becoming anxious.
Engage in role-playing and encourage practice of Enables client to use skill more effectively
stress relief techniques when client is not feeling (automatically) as needed and helps individual
anxious. handle problems/pressures as they occur.
Encourage creative activities and development of Helps expand positive energy and
attention.
greater leisure skills. Enhances self-worth.
Encourage participation in regular exercise program, Participation in individually prescribed
activities
sporting activities, occupational/recreational therapy and large motor exercises provides safe,
effective
including brisk walls, jogging, punching bag, methods for discharging pent-up tensions,
volleyball. learning to trust self, and enhancing self-esteem.

Exercise releases endorphins, enhancing sense

of
well-being. Note: Exercise therapy does not
need
to be aerobic or intensive to achieve desired
effect.
Involve in group settings, encouraging and Increases opportunities for/reinforcement of
reinforcing appropriate participation. Redirect into desired, productive interaction style.
Sharing with
activities, e.g., interaction with others, as indicated. others decreases sense of being the only
one.
Client may learn new coping styles from stress of

participation as well as from peers who have

experienced similar stressors.
Deal with physical complaints in matter-of-fact style. Detection of physical problems and
prevention of
Investigate appropriately if new; redirect if not new discounting client’s discomfort are
important.
or validated. Do not ask how client is or feels. Help Reduces reinforcement for focusing on
self and
client recognize physical symptoms as anxiety symptoms while providing opportunity and
signals when appropriate. Note history of mitral reinforcement for other-directed, more
appropriate
valve prolapse (MVP). interaction style. Note: Focus on physical
complaints occurs in depressed persons in about
25% of cases. Palpitations resulting from MVP
may
increase anxiety to panic state and require
medical
evaluation/treatment.
Collaborative
Provide phototherapy as indicated. Light therapy using white fluorescent lights
(2500
to 10,000 lx) at a distance of 3 feet from the
client
for several hours a day has been found to
improve
 mood within 2 to 4 days in presence of SAD.
Treatment has few disadvantages, although
relapse is common if therapy is discontinued. For

this reason, light therapy may be combined with

medication.

NURSING DIAGNOSIS PHYSICAL MOBILITY, impaired/SELF CARE

deficit (specify)
May Be Related to: Disinterest or unconcern; lack of energy/inertia;
psychomotor retardation
Impaired self-concept; depression; severe
anxiety
Possibly Evidenced by: Impaired ability to make decisions, such as
whether to get out of bed, what to wear/eat;
disheveled appearance
Reports of “I can’t/don’t want to” or “Wait until
later” to perform self-care activities
Requests for help in the absence of physical
incapacity
Inactivity
Desired Outcomes/Evaluation Criteria— Verbalize understanding of own situation and
Client Will: individual treatment regimen.
Demonstrate resumption of activities, increased
concern/attention to grooming and hygiene, and
behaviors to begin to direct own life.
Initiate/perform self-care and other activities
independently.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Speak directly to client; respect individuality and Promotes sense of worthwhileness of the person.
personal space as appropriate.
Provide structured opportunities for client to make Begins to establish own ability to make
decisions
choices of care, (e.g., what to wear today, what and accept/deal with consequences.
activity to participate in).
Be aware of the amount of time client actually Immobility places client at increased risk for skin
spends in bed/chair, especially clients who appear lesions/decubitus, circulatory stasis,
constipation,
in a poor nutritional state. and infection.
Examine skin over bony prominences for redness Identifies compromised tissues receiving
(include heels) after client has been in bed/chair decreased circulation (because of prolonged
awhile. pressure) and requiring prompt intervention.
Encourage/provide skin care with attention to Until etiological factors are remedied (immobility
cleanliness; gentle massage and lotion every 2–3 and nutritional status) these actions help
prevent
hours. Recommend change position every 2 hours, skin breakdown by alleviating pressure
and
including bed to chair or to stroll “once around the promoting circulation. Also stimulates
peristalsis,
day room.” Progress to regular exercise program. enhancing elimination.
Set progressive activity goals with client. Reduces risks of complication related to
sedentary
lifestyle/immobility. Activity can also release
natural endorphins, which help elevate mood.
Monitor intake and output. Note color/ Direct indicators of individual needs/presence of
concentration of urine. Observe for complicationsproblems. Poor hydration directly affects tissues
of reduced fluid intake (e.g., dry mucous membranes (increasing risk of damage/breakdown in
face of
and lips, poor skin turgor, constipation), and treatdecreased mobility) and elimination.
accordingly.
Offer fluids frequently/leave small amounts of Improves overall intake in depressed person to
fluid within easy reach. Encourage intake of at least whom everything seems too difficult.
Client may
1500–2000 ml/day. drink because it is available. Small amounts

prevent guilt over things being “wasted” if all is

not consumed. Prevents options for negative self-

reinforcement (e.g., “nothing available,” “can’t
drink that much”).
Note dietary intake/deficits. Increase roughage; Promotes general well-being, helps increase
provide fruit juices, stimulant beverages (hot or energy level, and promotes improved pattern of
caffeine-containing, if tolerated). elimination. Fiber improves stool consistency and

bowel function. Caffeine has a cholinergic effect,

and some juices, such as prune, contain a by-
product that stimulates intestinal mobility.
Perform/assist with needed self-care activities for Ensures that needed activities are accomplished
if
client, as necessary. Note frequency of elimination client is unable/unwilling to perform
alone.
pattern. Promotes prompt intervention as indicated,
reducing risk of complications (e.g.,
constipation).
Provide/obtain needed equipment, client’s own Availability may prompt performance; having
supplies, clothing. one’s own things enhances self-esteem,
autonomy.
Choose one self-care activity and plan with client Assists client toward self-care in a slow and
how to implement in a simple, concrete fashion. achievable manner. Depressed clients feel
overwhelmed, and it is important that success is
experienced l task at a time.
Provide low-key reinforcement for improved Enhances self-esteem; low-key style avoids
functioning in this area. provoking discounting, self-derogation.
Give low-key reminder regarding need to performGentle prodding can be helpful to the client;
a self-care activity. however, reminders may be perceived as
criticism
and can feed into self-derogatory thinking.

Collaborative
Refer to occupational/recreational therapy These activities help to discharge anger and
involving motor activities (e.g., walking, working aggression and relieve guilt, as well as build self-
with clay, aerobic exercise, crafts, activities of daily confidence and prepare client for return to

living). previous occupation/leisure-time activities.

Encourage beautician/barber appointments, if Can enhance self-image, stimulate participation
in
services accessible. self-care activities.
Administer stool softener/bulk preparation. May be used to supplement dietary
inadequacies/
soften stool until normal stool is established.
Provide glycerine suppository or laxative product Prevents impaction and helps to restore regular
according to protocol, if no bowel movement pattern.
occurs.

NURSING DIAGNOSIS NUTRITION: altered, less/more than body

requirements
May Be Related to: Inappropriate nutritional intake to meet
metabolic needs
Possibly Evidenced by: Lack of interest in eating/food or choosing
nutritional foods; aversion to eating
Dysfunctional eating pattern (e.g., eating in
response to internal cues other than hunger)
Recent weight loss, poor muscle tone, decreased
subcutaneous fat/muscle mass; pale conjunctiva
and mucous membranes; or weight gain
Sedentary activity level
Desired Outcomes/Evaluation Criteria— Demonstrate progressive weight gain/loss toward
Client Will: goal.
Be free of signs of malnutrition with
normalization of laboratory values.
Identify actions/lifestyle changes to regain and/or
to maintain appropriate weight.
ACTIONS/INTERVENTIONS RATIONALE

Independent
Monitor/record amount and type of food eaten, Provides baseline data and documents change/
calculate total calorie intake. Note how client progress toward goal.
perceives food and the act of eating.
Explain to client that malnutrition itself decreases May provide incentive to eat, increasing
energy levels and ability to think cohesively (e.g., cooperation with regimen and intake of
nutritious
decreased protein and vitamin B affect and may foods.
deepen depression).
Determine calorie requirements based on physical Caloric requirements need to be adapted
to
factors and activity. Increase calorie intake as provide sufficient energy to meet expenditures/
activity level increases. maintain appropriate weight.
Monitor body weight, depending on the seriousness Provides information about therapeutic
needs/
of the problem and the client’s response to being effectiveness. Note: Increased appetite is one of
the
weighed. earliest responses to antidepressant use.
Avoid getting into a “power struggle” about these Focuses attention on food and weight,
issues. overemphasizing them (possibly providing
secondary gain) rather than underlying
dynamics.
Provide small meals and interval feedings, A full meal may look like an insurmountable
emphasizing nutritious choices (e.g., high protein/ challenge, especially for client who is
depressed.
carbohydrates, increased fiber).
Identify and obtain foods client thinks would be May enhance desire to eat and promote
interesting/appealing. Use family/friends as increased/balanced intake. Family can provide
resources as indicated. information about client’s likes and dislikes,
other
helpful ideas to increase food intake.
Feed client, if indicated by physical condition and Assisting client to eat can help to meet
nutritional
refusal/inability to eat. needs.
Collaborative
Consult with dietitian as necessary. Helpful in determining individual needs,
alternate
dietary therapy, reinforcing proper eating habits.
Monitor laboratory studies (e.g., serum albumin, Detects deficiencies/imbalances, identifies
prealbumin, glucose, electrolytes, nitrogen balance). therapeutic needs/effectiveness.
Provide tube feeding, as indicated. May be necessary when client refuses or is
unable
to eat and client safety/condition requires.
 NURSING DIAGNOSIS SLEEP PATTERN disturbance
May Be Related to: Biochemical alterations (decreased serotonin)
Unresolved fears and anxieties
Possibly Evidenced by: Difficulty in falling/remaining asleep, early
morning awakening/awakening later then desired
Reports of not feeling rested
Hypersomnia, using sleep as an escape
Desired Outcomes/Evaluation Criteria— Identify interventions to promote/enhance sleep.
Client Will: Report falling asleep within 30 minutes of retiring
and sleeping 4–6 hours before awakening.
Verbalize having had a satisfactory night’s
sleep/feeling well rested.
Refrain from using sleep as a means of escaping
real feelings and fears.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Identify nature of sleep disturbance and variation Patterns provide clues to help client and nurse to
from usual pattern (e.g., insomnia [difficulty falling work together to solve the problem.
asleep or may awaken early and be unable to return
to sleep] or hypersomnia).
Assess what client does when awake and plan with Clients often awaken and ruminate about
client to change pattern as indicated. themselves in a hopeless/helpless manner.
Having
client set aside a period during the day to
ruminate may extinguish this behavior at night.
Establish a realistic goal with client. Some individuals have unrealistic ideas of a
“normal” night’s sleep.
Identify previous bedtime rituals that may have Restoring familiar, successful rituals may allow
the
been interrupted by illness/hospitalization, and client to reestablish usual pattern.
reestablish when possible.
Decrease afternoon and evening caffeine intake Avoids stimulants, which may affect ability to
(coffee, tea, chocolate, colas). fall/stay asleep.
Restrict evening fluids and have client void before Reduces need to rise at night to void.
retiring.
Provide light bedtime nourishment, such as milk, if Milk (with L-tryptophan) is thought to be
helpful
client likes it and it is not otherwise contraindicated. in promoting sleep. Snack may prevent
awakening
during night because of hunger.
Encourage relaxation exercises to soft music prior to Aids in release of tension and promotes
falling
sleep. asleep.
Reduce environmental stimuli (e.g., lights, noises, Decreases distracting stimuli that may
interfere
loudspeakers, etc.). Encourage use of white noise as with sleep.
appropriate.
Provide night lights, environmental control (room May prevent confusion upon awakening. Ensures
adequately warm or cool); appropriate nightwear/ personal comfort, promotes sleep, sense
of
bedding, including special blanket/pillow, which security.
can be brought from home.
Schedule treatments, procedures, assessments, and Prevents unnecessary interruption during
sleep.
medications during the daytime.
Increase daytime activity, including stimulating Increased activity without overexertion promotes
diversionary activities in daily schedule. Set limits sleep. Note: If client must nap, morning
napping
on time spent in room, discourage returning to bed disrupts sleep pattern less than afternoon
naps.
during the day.
Explore fears and feelings that sleep is helping toIdentifies these factors so they can be dealt with
to
suppress. enable client to progress with therapy.

Collaborative
Provide hypnotic or sedative only if other methods Products may suppress REM sleep,
resulting in
fail. not feeling rested upon awakening.
Recommend use of/administer antidepressants or Decreases daytime drowsiness and aids
sleeping at
other medication with sedative side effects at night.
bedtime when possible.

NURSING DIAGNOSIS SOCIAL ISOLATION/SOCIAL INTERACTION,

impaired

May Be Related to: Alterations in mental status/thought process

(depressed mood)
Inadequate personal resources; decreased
energy/inertia
Difficulty engaging in satisfying personal
relationships
 Feelings of worthlessness/low self-concept;
inadequacy in or absence of significant purpose
in life
Knowledge/skill deficit about social interactions

Possibly Evidenced by: Verbalization/demonstration of awareness that

interpersonal or social interactions do not have
desired, satisfactory, or reinforcing outcomes
Changes in patterns or
interacting/communication (e.g., slowed speech,
latencies, decreased amount of speech,
muteness)
Decreased involvement with others; expressed
feelings of difference from others; dysfunctional
interaction with peers, family, and/or others
Refusing invitations/suggestions of social
involvement; remaining in home/room/bed
Desired Outcomes/Evaluation Criteria— Attend/then participate in a specific number of
Client Will: activities per day/week.
Participate in 1:1 interaction for specified
number of minutes.
Complete errands, initiate socialization activities
a specific number of times per week.
Reinstate 2 previously enjoyed activities
involving others or develop new ones.
Verbalize increased satisfaction with outcomes of
social interactions.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Be consistent and on time in planned meetings with Client will experience lateness as further
evidence
client. of decreased self-worth. In building trust, client
needs to know that the nurse will follow through
on previously agreed meetings/commitments.
Greet routinely, beginning with client’s name andReinforces individuality, gets attention. Provides
a
personal comment (e.g., appearance, clothing); “no-demand” acceptance, opportunity to interact

share pertinent information from shift report, if client chooses. Matter-of-fact manner prevents
observations, etc. without concern for response by demand for client to provide a response
when
client. depressed feelings interfere.
Use touch, unless contraindicated. Touch is a basic form of communication and can
help client in interactions, demonstrate caring,
and
reinforce sense of self-worth.
Start conversation and “give” client a topic (e.g., Initiating activity is often very difficult for client
unit or world event, OT project, etc.). and having an assignment helps get the activity
started.
Keep input fairly short and concrete. Ask only one Requires less effort for client to attend to
and
question (about one thing) at a time. Avoid asking retain. Promotes focus and requires that
client put
“yes-no” and “why” questions. thinking into response. “Why” questions are
often
perceived as threatening/demanding of an
answer.
Take adequate time; wait patiently for responses. Indicates interest, enhances self-esteem.
Observe and give feedback regarding the feeling Recognition of these feelings demonstrates
tone conveyed and interaction style observed. empathy, sensitivity. Promotes understanding of
how client is perceived by others, when
discomfort
and feelings of inadequacy have been
experienced
and provides opportunity for insight/change.
Emphasize attendance at routine unit activities as Starting with achievable goals gives client
the
well as nondemanding activities (e.g., movies). ability to succeed and enhance self-esteem.
Initially emphasize attendance rather than Attendance precedes participation.
participation or enjoyment to be gained.
Contract with client (e.g., for nonsuicidal client, 1 Involving client in decision-making increases
hour of attendance at an activity is rewarded by 1 sense of control over situation and may
promote
hour in room without being “pestered”). cooperation.
Gradually increase activity schedule. Involve withEnhances changes of cooperation, diminishes
one other person or in quiet activity in day area. threat, promotes progression of interaction.
Avoid taking client’s difficulty in responding or Client will try to reinforce feeling of
negative/hostile responses personally. “worthlessness” by trying to create negative
responses from others. Working with depressed
client requires much patience and ability to
recognize small goals as improvement.
Encourage visits by friends, relatives, other social Helps reestablish neglected, previously
rewarding
contacts identified/located by family member. relationships.
Determine what the client’s interests/activities Revitalizes memories from a time when client felt

were, and ask client to share those. Let client teach better, promoting client’s individuality
and sense
others about past skills by asking questions, of offering self to others. Encourages resumption
indicating desire to learn about client’s contributions of previously enjoyed activities, reduces
sense of
to job and family. Obtain hobby equipment from isolation, and increases sense of purpose.
home, if indicated.
Involve family and friends to escort/transport on Events such as these require little of client but
outings and functional (shopping, business, increase social involvement and yield social
obtaining belongings at home) or social activities reinforcement. Decreases sense of isolation from
(a brief meal, religious service, etc.). outside world.
Assist individual to assess own satisfaction with Helps client plan what is to be expected from
outcome(s) of interpersonal interactions. Avoid interacting and how client can behave to realize
asking client if activities are “enjoyable” or “fun.”those expectations. Involves the client in
problem
identification and helps to evaluate whether
goals
are realistic. Note: Cheerfulness may be
interpreted
as false.
Request feedback on outings and activities from The goal is to increase involvement, and because

both client and others involved (therapists, client will likely report a less successful event
than
companions). a more objective observer, input is important
from
both. The client can also hear others’ perception
of
an event, which can serve to validate/add to the
client’s perception.
Use social skills training model to help client identify Client may need to learn social skills and
practice
alternative strategies; role-play/rehearse new (more new behaviors. Improved social skills are
more
effective) behavior; obtain feedback and reinforce- likely to have results that satisfy/reinforce
ment; try new behavior in a “real situation.” interactions.
Use group situations for maximum impact/reinforce- Group situations provide more
opportunity
ment (e.g., group therapy, OT, RT, etc.). for interactions, feedback, reinforcement.
Give positive reinforcement regarding attendance/ Client is unable to discount reinforcement
and is
performance (e.g., increased involvement in groups, thus reinforced for participation. Positive
demonstration of more effective social skills). reinforcement increases the reward for trying the

new tactics, encourages repetition of desired

behaviors.
Assist client in identifying the natural reinforcers that These reinforcers will increase the client’s
occur with more effective interactions. confidence and strengthen the behavior.

NURSING DIAGNOSIS SEXUAL dysfunction/SEXUALITY PATTERNS,

altered
 May Be Related to: Decreased energy and concern, apathy; loss of
sexual desire
Decreased self-esteem; values conflict
Misinformation/misconceptions about sexual
functioning/behavior
Impaired relationship with SO; psychosocial
abuse (e.g., harmful relationships)
Possibly Evidenced by: Reported difficulties, limitations, or changes in
sexual behaviors/activities (e.g., inability to
achieve desired satisfaction, women may
express a loss of interest; men may experience
impotence and loss of libido)
Actual/perceived limitation imposed by
condition/therapy
Alteration in relationship with partner
Desired Outcomes/Evaluation Criteria— Verbalize understanding of effect of depression
Client Will: on sexual functioning.
Identify stressors that contribute to dysfunction
and make changes as able.
Resume sexual functioning at level desired/as
agreed on by client and partner.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Review client’s sexual history and degree of satis- Establishes a baseline and elicits client’s
feelings
faction prior to depression. about previous sexual satisfaction. Note: May
need
to discuss this when client is well into recovery,
as
feelings of self-worth are intertwined with
feelings
about sexual satisfaction.
Assist client to define expectations for sexual satis- Planning can help the client identify more
clearly
faction and decide what can be done to attain these. what own desires are and whether they
are
reasonable/attainable.
Provide sex education as necessary. Include Often sexual problems are partly ignorance and
significant other/partner as appropriate. misconceptions about sexual facts, and
knowledge
can assist with problem resolution. Note: Client
 may need support to terminate abusive
relationships/initiate involvement with others.
Review medication regimen; observe for side effects Many medications can affect libido, cause
delayed
of drugs prescribed. or inability to achieve orgasm, impaired erectile
capacity, delayed ejaculation, or impotence,
putting a strain on a relationship and interfering
with treatment. Evaluation of drug and individual

response is important to ascertain whether drug

is
responsible for the problem.
Discuss appropriateness of delaying scheduled anti- Increases likelihood that client will
continue
depressant dose until after coitus. therapeutic regimen if it does not interfere with
sexual performance.

Collaborative
Evaluate need for dose reduction, drug substitution, May help reduce unwanted side effects of
or combination therapy. medication.
Refer for further counseling/sex therapy as indicated. May need additional or more in-depth
assistance if
problems are severe/unresolved as depression
lifts.

NURSING DIAGNOSIS FAMILY PROCESSES, altered

May Be Related to: Situational crisis of illness of family member
Developmental crisis (e.g., loss of family
member/relationship)
Possibly Evidenced by: Expressions of confusion; statements of difficulty
coping with situation
Family system not meeting needs of its
members; difficulty accepting or receiving help
appropriately
Ineffective family decision-making process;
failure to send and receive clear message.
Desired Outcomes/Evaluation Criteria— Express feelings freely and appropriately.
Family Will: Demonstrate individual involvement in
problem-solving processes directed at
appropriate solutions for the situation/crisis.
Encourage and allow member who is ill to handle
situation in own way, progressing toward
independence.
Identify/use community resources appropriately.
ACTIONS/INTERVENTIONS RATIONALE

Independent
Assess degree of family dysfunction and current Identifies problems of individual family members,

coping methods of individual members. provides direction for intervention. Areas most
affected are communication, marital adjustment
and satisfaction, expressed emotion and
problem-
solving. Note: These families tend to have a
greater degree of functional impairment than

families dealing with other major mental

illnesses.
Identify family developmental stage (e.g., newly Developmental stage may be a factor in current
married couple/divorced, children leaving home); situation and client’s depression. Disruption of
components of family and client’s role in the family client’s role may contribute to family
constellation. disorganization/strain on other family members
who have to step in and assume duties client
usually takes care of.
Identify patterns of communication within the Dysfunctional communication (such as high
levels
family. Are feelings freely expressed? Is blame or of tension, negative expressions, self-
fault assigned? What is the process of decision- preoccupation, diminished nonverbal patterns of
making in the family and who makes the decisions? support) contributes to feelings of
inadequacy,
What is the interaction between family members? rejection, and inability to cope on the part
of the
members of the family.
Acknowledge difficulties observed while giving Reassures family that feelings are acceptable
and
permission to express feelings and discussing more can be dealt with appropriately.
effective methods of communication.
Note the extent of feelings of powerlessness and lack Client often displays hopelessness and
anhedonia,
of pleasure in daily life. Discuss effect on family which are very stressful and can be disruptive to
members. family functioning. Promotes understanding that
these feelings are part of the illness and enables
family members to deal with own frustrations
appropriately.
Provide information as necessary in verbal, written, Provides opportunity for family members
to
and/or tape format as appropriate. review and incorporate new knowledge to assist
in
resolution of current situation.
Establish/discuss goals and expectations of family Realistic expectations of abilities of client
to
members/clients following discharge from care. Let assume place in the family are crucial to
continued
individuals know the importance of “taking it slow” recuperation. Family needs to understand
that
and not pressuring each other to change. members need to continue to work on new style
of
communication and changing ways of dealing
with conflict
issues.

Collaborative
Involve in group, family and psychotherapy, as Opportunity to hear others discuss shared
indicated. problems and ways of handling can encourage
family members to look at new ways of
interacting. Note: Children living in this setting

have as high as a 45% risk of developing

affective
disorders and may require focused therapy.
Provide information about resources available as Assistance may be needed for family members
to
needed (e.g., social services, homemaker assistance, assimilate new skills and begin to make
necessary
counseling [e.g., marital, spiritual], visiting nurse lifestyle changes to promote wellness. There is a
services). high rate of relapse for individuals dealing with
major depression, and divorce rates are 9 times
higher in the presence of greater expressed
emotion than the national average.

NURSING DIAGNOSIS KNOWLEDGE deficit [LEARNING NEED]

regarding diagnosis, prognosis, treatment
and self care needs
May Be Related to: Lack of information about pathophysiology and
treatment of depression
Misconceptions about mental illness
Possibly Evidenced by: Inaccurate statements about own situation and
potential for recovery
Lack of follow-through with treatment regimen
Inappropriate behavior, apathy
Desired Outcomes/Evaluation Criteria— Exhibit increased interest, participating in
learning
Client Will: process.
Verbalize understanding of condition, prognosis,
and therapeutic regimen.
Assume responsibility for following through on
treatment options.
Identify/use resources appropriately.
ACTIONS/INTERVENTIONS RATIONALE

Independent
Determine level of knowledge, mental/emotional May be first experience with illness/mental
health
readiness for learning. system. Previous experience may or may not
have
provided accurate information. May be too
depressed to access information accurately.
Provide information about depression/treatment as Provides opportunity for client to learn
about own
indicated. Give written as well as verbal information. situation and enhances recall.
Provide information about drug therapy and Client needs to know what to expect from drug
potential side effects, e.g., anticholinergic effects, trial. Knowledge can increase cooperation
with
sedation, orthostatic hypotension of antidepressants; drug regimen. Particularly, clients need to
be
possibility of hypertensive crisis if individual aware that improvement may not occur for 4–6
consumes foods containing tyramine while taking weeks after drug therapy is begun, and
that side
MAOIs; dysrhythmias; photosensitivity; reduction of effects will generally improve/disappear
within 2
seizure threshold. weeks.
Encourage frequent fluids, lip salve, ice chips, as Provides relief of dry mouth caused by
indicated. anticholinergic effect of drug therapy.
Suggest medication dosage be taken at bedtime, Sedative effect may be helpful in promoting and
when appropriate. maintaining sleep.
Discuss importance of monitoring blood pressure as Most common side effect of
antidepressants is
indicated. Suggest client rise slowly from sitting/ orthostatic hypotension, which can result in
lying position. dizziness, injury following sudden position
change.
Review diet restrictions (e.g., tyramine-free diet Necessary to avoid interaction (hypertensive
[avoid aged cheeses, fermented foods, wine/beer, crisis) when MAOIs are used, and for 2
weeks
liver, sour cream/yogurt, soy sauce, yeast products], following discontinuation of drug.
limitation of caffeine).
Discuss importance of healthy diet and regular Important for general well-being. Additionally,
exercise. bone mineral density of depressed clients may
be
significantly lower, requiring focused
interventions.
Emphasize necessity to avoid driving or operating Side effects of drowsiness or dizziness are
usually
dangerous machinery during initiation/changes in self-limiting but require adjustment in
activities
medication regimen. until resolved.
Encourage client to stop smoking, avoid alcohol Smoking increases metabolism of tricyclic
intake. medications, necessitating adjustment in dosage
to
achieve therapeutic effect. Alcohol potentiates
CNS effects of antidepressants.
Instruct client to contact provider before taking Many medications contain substances that, in
other prescription or OTC medications and to notify combination with antidepressants, could
other healthcare providers of drug regimen. precipitate a life-threatening crisis.
Discuss use of identification bracelet/card. Provides information, if needed, in emergency
situation to prevent sudden termination of
medication, which could be detrimental.
Reinforce importance of not stopping drugs abruptly. Sudden cessation of drugs can result in
untoward
effects (e.g., may aggravate condition,
deepening |
depression, and cause withdrawal with
nausea/vomiting and diarrhea).
Refer to resources/agencies (e.g., social services, May be helpful to client for long-range planning
homemaker/baby-sitting, support groups). for regaining/maintaining wellness.

NURSING DIAGNOSIS INJURY, risk for [effects of ECT therapy]

Risk Factors May Include: Electroconvulsive effects on the cardiovascular,
respiratory, musculoskeletal, and nervous
systems
Pharmacological effects of anesthesia
Possibly Evidenced by: [Not applicable; presence of signs and symptoms
establishes an actual diagnosis.]
Desired Outcomes/Evaluation Criteria— Maintain physiological stability, free of
Client Will: injury/complications.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Review medical testing (e.g., CBC, ECG, chest x-ray, A complete medical workup can identify
urinalysis, and x-rays of lateral aspects of the spine) preexisting problems and the potential for
before procedure. problems, which should be reported to personnel

involved with procedure.

Discuss what will be done (e.g., anesthesia, muscle Knowledge can reduce anxiety and
decrease fear
relaxants, oxygenation, drugs used, who will be response and is necessary for informed consent
to
with the client, and how the client is likely to feel procedure. Client will feel more secure knowing
after ECT). nurse will be there upon awakening. Awareness
 that confusion/memory loss are temporary helps
alleviate associated fears.
Verify informed consent/signed permission form Indicates that client agrees to procedure and
has been obtained. received appropriate information.
Have client empty bladder, remove jewelry/hair Reduces risk of injury/aspiration.
decorations, eyeglasses/contacts, and dentures
before treatment.
Orient client upon awakening after the treatment, Short-term memory may be affected, and
client
and support client while immediate confusion awakens confused. May be frightened by
amnesia.
clears. Confusion increases with each treatment,
knowledge that after-effects disappear will be

reassuring.
Monitor vital signs every 15 minutes until stable. Premedication, muscle relaxants, and anesthesia

may produce dysrhythmias and respiratory

depression, which need immediate intervention.
Have emergency equipment, suction, Ambu bag, Prompt treatment of respiratory depression/
etc. available. airway obstruction can prevent/correct life-
threatening complications.

Collaborative
Restrict oral intake as indicated. Reduces risk of vomiting/aspiration.
Provide supplemental oxygen as necessary. Provides for optimum oxygenation during period
of reduced ventilation.
Administer preprocedural medications as Decreases secretions to prevent aspiration and
indicated (e.g., atropine sulfate). increases heart rate to offset response to vagal
stimulation caused by ECT.