1. Nursing C A R E P L A N Depression
ASSESSMENT DATA
EXPECTED OUTCOMES
Nursing
Diagnosis (or Planning)
• Suicidal ideas or behavior
• Slowed mental processes
• Disordered thoughts
• Feelings of despair,
hopelessness, and
worthlessness
• Guilt
• Anhedonia (inability to
experience
pleasure)
• Disorientation
• Generalized restlessness or
agitation
• Sleep disturbances: early
awakening,
insomnia, or excessive
sleeping
• Anger or hostility (may not
be overt)
• Rumination
• Delusions, hallucinations,
or other psychotic
symptoms
• Sexual dysfunction:
diminished interest
in sexual activity, inability to
experience
pleasure
• Fear of intensity of feelings
• Anxiety
➤ Ineffective
Coping
Inability to form a
valid appraisal of
the stressors,
inadequate choices
of practiced
responses, and/or
inability to use
available resources
Immediate
The client will
• Be free from self-inflicted
harm
• Engage in reality-based
interactions
• Be oriented to person, place,
and time
• Express anger or hostility
outwardly
in a safe manner
Stabilization
The client will
• Express feelings directly
with congruent
verbal and nonverbal
messages
• Be free from psychotic
symptoms
• Demonstrate functional level
of
psychomotor activity
Community
The client will
• Demonstrate compliance
with and
knowledge of medications, if
any
• Demonstrate an increased
ability to
cope with anxiety, stress, or
frustration
• Verbalize or demonstrate
acceptance
of loss or change, if any
• Identify a support system in
the
community
EVALUATION
IMPLEMENTATION
Nursing Interventions *denotes
collaborative interventions
RATIONALE
Provide a safe environment for
the client.
Physical safety of the client is a
priority. Many common items
and environmental situations
may be used by the client in a
self-destructive manner.
Continually assess the client’s
potential for suicide.
Depressed clients may have a
potential for suicide that may or
may not be expressed and that
may change with time. You
must remain aware of this
suicide potential at all times.
Observe the client closely,
especially under the following
circumstances:
After antidepressant medication
begins to raise the client’s
mood
After any sudden dramatic
behavioral change (sudden
cheerfulness, relief, freedom
from guilt, 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.
These changes may indicate
that the client has come to a
decision to commit suicide.
Unstructured time on the unit
Risk of suicide increases when
the client’s time is unstructured.
Times when the number of staff
on the unit is limited
Risk of suicide increases when
observation of the client
decreases.

2. Prep by: Dr. James M. Alo, RN,MAN,MAPsycho,PhD.