Psychiatric Mental Health Nursing by Videbeck

344 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS

clients cannot sleep or they feel exhausted and un-
refreshed no matter how much time they spend in
bed. They lose interest in sexual activities, and men
often experience impotence. Some clients neglect per-
sonal hygiene because they lack the interest or en-
ergy. Constipation commonly results from decreased
food and fluid intake as well as inactivity. If fluid in-
take is severely limited, clients also may be dehy-
drated.

DEPRESSION RATING SCALES

Clients complete some rating scales for depression;
mental health professionals administer others. These
assessment tools, along with evaluation of behavior,
thought processes, history, family history, and situ-
ational factors, help to create a diagnostic picture.
Self-rating scales of depressive symptoms include the
Zung Self-Rating Depression Scale and the Beck De-
pression Inventory. Self-rating scales are used for
case-finding in the general public and may be used
over the course of treatment to determine improve-
ment from the client’s perspective.
The Hamilton Rating Scale for Depression (Table
15-6) is a clinician-rated depression scale used like a
clinical interview. The clinician rates the range of
the client’s behaviors such as depressed mood, guilt,
suicide, and insomnia. There is also a section to score
diurnal variations, depersonalization (sense of unreal-
ity about the self), paranoid symptoms, and obsessions.

Data Analysis

The nurse analyzes assessment data to determine
priorities and to establish a plan of care. Nursing di-
agnoses commonly established for the client with
depression include the following:

• Risk for Suicide


• Imbalanced Nutrition: Less Than Body
  Requirements


• Anxiety


• Ineffective Coping


• Hopelessness


• Ineffective Role Performance


• Self Care Deficit


• Chronic Low Self-Esteem


• Disturbed Sleep Pattern


• Impaired Social Interaction

Outcome Identification

Outcomes for clients with depression relate to how the
depression is manifested—for instance, whether or
not the person is slow or agitated, sleeps too much or
too little, or eats too much or too little. Examples of

outcomes for a client with the psychomotor retarda-

tion form of depression include the following:

• The client will not injure himself or herself.


• The client will independently carry out
  activities of daily living (showering, changing
  clothing, grooming).


• The client will establish a balance of rest,
  sleep, and activity.


• The client will establish a balance of adequate
  nutrition, hydration, and elimination.


• The client will evaluate self-attributes
  realistically.


• The client will socialize with staff, peers, and
  family/friends.


• The client will return to occupation or school
  activities.


• The client will comply with antidepressant
  regimen.


• The client will verbalize symptoms of a
  recurrence.

Intervention

PROVIDING FOR SAFETY

The first priority is to determine if a client with de-

pression is suicidal. If a client has suicidal ideation

or hears voices commanding him or her to commit

suicide, measures to provide a safe environment are

necessary. If the client has a suicide plan, the nurse

asks additional questions to determine the lethality

of the intent and plan. The nurse reports this infor-

mation to the treatment team. Health care personnel

follow hospital or agency policies and procedures for

instituting suicide precautions(e.g., removal of

harmful items, increased supervision). A thorough

discussion is presented later in the chapter.

PROMOTING A THERAPEUTIC RELATIONSHIP

It is important to have meaningful contact with clients

who have depression and to begin a therapeutic rela-

tionship regardless of the state of depression. Some

clients are quite open in describing their feelings of

sadness, hopelessness, helplessness, or agitation.

Clients may be unable to sustain a long interaction,

so several shorter visits help the nurse to assess sta-

tus and to establish a therapeutic relationship.

The nurse may find it difficult to interact with

these clients because he or she empathizes with such

sadness and depression. The nurse also may feel un-

able to “do anything” for clients with limited responses.

Clients with psychomotor retardation (slow speech,

slow movement, slow thought processes) are very non-

communicative or may even be mute. The nurse can

sit with such clients for a few minutes at intervals