9 Major Depression Nursing Care Plans

Risk For Self-Directed Violence

Clients diagnosed with major depression are at an increased risk for self-directed violence due to their intense feelings of hopelessness, helplessness, and despair. These clients may also have impaired decision-making abilities and difficulty coping with stress, leading to an increased risk for self-harm. In severe cases, suicidal ideation and intent may be present, making it critical to closely monitor and address these risks in the care plan.

Nursing Diagnosis

• Risk for self-directed violence

Risk factors

• Anhedonia, helplessness, hopelessness
• Loneliness
• Social isolation
• Severe personality disorder/ depression/ psychosis, substance abuse

Possibly evidenced by

• Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

• The client will seek help when experiencing self-destructive impulses.
• The client will have a behavioral manifestation of absent depression.
• The client will have satisfaction with social circumstances and achievements of life goals.
• The client will identify at least two-three people he/she can seek out for support and emotional guidance when he/she is feeling self-destructive before discharge.
• The client will not inflict any harm to themself or others.
• The client will identify support and support groups with whom he/she is in contact within one month.
• The client will state that he/she wants to live.
• The client will start working on constructive plans for the future.
• The client will demonstrate compliance with any medication or treatment plan within the next two weeks.
• The client will demonstrate alternative ways of dealing with negative feelings and emotional stress.

Nursing Assessment and Rationales

1. Identify the level of suicide precautions needed. If there is a high risk, and does hospitalization require it? Or if there is a low risk, will the client be safe to go home with supervision from a family member or a friend?
A client with a high risk will require constant supervision and a safe environment. Assess if the client has admitted previous suicide attempts, abuse any substances, has no peers/friends, and has any suicide plans. When the client has contemplated or attempted suicide, the burden is on the healthcare professional to directly explore the situation with the client in as much detail as possible to determine the current presence of suicidal ideation as well as accessible means and plans (Halverson & Bienenfeld, 2023).

2. Check for the availability of the required supply of medications needed.
Normally, a suicidal client’s medical supply should be limited to 3 to 5 days. Clients who attempt to commit suicide with prescribed medications represent one of the greatest clinical challenges. The dilemma involves balancing the fact that psychotropic drugs alleviate mental illness symptoms with the reality that some clients will use the very same medications to commit suicide. A study points out the need to pay attention to the number of stockpiled medications available to potentially self-destructive clients (Halverson & Bienenfeld, 2023).

3. Assess the client presenting with somatic symptoms carefully for an indication of depressive disorder.
Clients with major depressive disorder may not initially present with a complaint of low mood, anhedonia, or other typical symptoms. In the primary care setting, where are many of these clients first seek treatment, the presenting complaints often can be somatic, such as fatigue, headache, abdominal distress, or changes in weight. Clients may complain more of irritability or difficulty concentrating than of sadness or low mood (Halverson & Bienenfeld, 2023).

4. Identify factors that predispose the client to depression.
A thorough family history is important because depression can be familial. Familial, societal, and environmental factors appear to play significant roles in the course of depressive illness in children and youths, even in preschool children. A study described anaclitic depression or marasmus in infants being raised in an orphanage and in hospitalized children whose parents were not allowed to visit (Halverson & Bienenfeld, 2023).

5. Perform a mental status examination.
The diagnosis of major depressive disorder is based on the history and the mental status examination. Children with major depressive disorder may present with initially misleading symptoms such as irritability, a decline in school performance, or social withdrawal. Older adults may present with confusion or a general decline in functioning; they also experience cognitive symptoms and fewer complaints of sad or dysphoric mood (Halverson & Bienenfeld, 2023).

6. Assess the client’s mental status regarding the potential for committing suicide.
Another mental status review is designed to focus on evaluating an individual’s potential for committing suicide. One specific concern is a flat affect by the client when describing their thoughts and plans of suicide and self-destructive behavior. Three types of thought changes represent the areas for major focus and concern: command hallucinations telling the client to kill themselves, delusions about the benefits of suicide, and an obsession with taking their own lives (Soreff & Xiong, 2022).

Nursing Interventions and Rationales

1. Encourage clients to express feelings (anger, sadness, guilt) and come up with alternative ways to handle feelings of anger and frustration.
Clients can learn alternative ways of dealing with overwhelming emotions and gain a sense of control over his/her life. In the earliest stages of psychiatric hospitalization, with the most severely ill clients whose behaviors make talk-based therapy impractical or impossible, sensitive relationship-building has to come first. At its core, relationship-building is about language. It calls for identifying a specific communicative channel to enable initial interpersonal contact (Birnbaum, 2017).

2. Contact the family, and arrange for crisis counseling.
Clients need a network of resources to help diminish personal feelings of helplessness, worthlessness, and isolation. Engaging the family can be a critical component of a treatment plan, especially for pediatric and late-onset depression. Family members are helpful informants, can ensure medication adherence, and can encourage clients to change behaviors that perpetuate depression (Halverson & Bienenfeld, 2023).

3. If hospitalized, follow unit protocols.
There are different measures for suicidal clients in the hospital, clinic, and community. If suicidality is present, hospitalization with the client’s consent or via emergency commitment should be undertaken unless there are clear-cut means to ensure the client’s safety while outpatient treatment is begun (Halverson & Bienenfeld, 2023).

4. Assist in establishing a safety plan.
The Joint Commission recommended the development of a collaborative safety plan as an alternative to no-suicide contracts. Safety planning has been found to be acceptable to and more feasible by both suicidal clients and staff. Clients report it helps maintain their safety. Crisis response planning, a form of safety planning, resulted in fewer suicide attempts, lower suicidal ideation, and greater treatment engagement than no-suicide contracts, according to a randomized clinical trial (Stanley et al., 2018).

5. Activate links to self-help groups.
Responding to calls for greater efforts to reduce youth suicide, the Garrett Lee Smith Memorial Act to date has provided funding for 68 state, territory, and tribal community grants, and 74 college campus grants for suicide prevention efforts. Efforts at universities, for example, include creating comprehensive networks of individuals who are trained to recognize signs, symptoms, and communications of suicide and responding by connecting students to needed resources (Soreff & Xiong, 2022).

6. Perform post-discharge follow-up interventions.
These interventions, particularly those that involve in-person and telephone contact, are effective for clients diagnosed with major depressive disorder. One ED study found a 30% lower suicide attempt rate with an intervention consisting of screening, providing basic written material on safety planning, and several calls to suicidal clients and their significant others (Stanley et al., 2018).

7. Prepare the client for electroconvulsive therapy (ECT) as indicated.
ECT is a highly effective treatment for depression, especially when the client has a high risk of suicide. The onset of action may be more rapid than that of drug treatments, with the benefit often seen within one week of commencing treatment. However, this modality still poses numerous risks, including those associated with general anesthesia, postictal confusion, and, more rarely, short-term memory difficulties (Halverson & Bienenfeld, 2023).

8. Provide close monitoring for pediatric clients taking antidepressants.
In October 2003, the FDA issued a public health advisory regarding reports of suicidality in pediatric clients being treated with antidepressant medications. However, these agents are not contraindicated because access was important for those who could benefit from it. Therefore, the FDA recommended that pediatric clients taking antidepressants should be provided with close monitoring. Close monitoring includes at least weekly face-to-face contact with clients or their family members or caregivers during the first four weeks of treatment; visits every other week for the next four weeks; visits at 12 weeks; and then visits as clinically indicated beyond 12 weeks (Halverson & Bienenfeld, 2023).

9. Remove anything that the client may use to hurt or kill themselves.
Remove sharp or potentially dangerous objects. Ask the client for any weapon, such as knives or pills, and secure them away from the client. A study of the association between the provision of mental health services and suicide rates found that removing ligature points (places where things like ropes could be attached) was associated with significant reductions in the overall psychiatric inpatient suicide rate and in the rate of inpatient suicide by hanging (Soreff & Xiong, 2022).

10. Administer antidepressants, as prescribed.
Selective serotonin reuptake inhibitors (SSRIs) have the advantage of ease of dosing and low toxicity in overdose. SSRIs are greatly preferred over the other classes of antidepressants for the treatment of children and adolescents, and they are also the first-line medications for late-onset depression. The adverse-effect profile of SSRIs is less prominent than that of some other agents, which promotes better adherence (Halverson & Bienenfeld, 2023).