Signs and Symptoms included: Depressed mood for ≥2wk, ↓pleasure (anhedonia) plus 4 or more: ↑↓appetite, ↓↑wt, psychomotor agitation or retardation, altered sleep, ↓concentration, ↓energy, suicidal ideation
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.
Nursing diagnosis: VIOLENCE, risk for self-directed
Risk factors may include: Depressed mood; Feelings of worthlessness and hopelessness; 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— Client Will: Voluntarily comply with suicide precautions, sign “no harm” contract. Verbalize a decrease/absence of suicidal ideas. State 2 reasons for not harming self. Commit no acts of self-violence.
Nursing care plan assessment and physical examination
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 selfworth/ 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
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).
Nursing care plan intervention and rationale
Identify degree of risk/potential for suicide through direct questions (e.g., “Have you thought about killing yourself?”). Assess seriousness of suicidal tendency, noting behaviors such as gestures, threats, giving away possessions, previous attempts, presence of hallucinations or delusions. (Use scale of 1–10 and prioritize care according to severity of threat, availability of means.)
Rationale: Degree of hopelessness expressed by client is important indicator of severity of depression and suicide risk. Eight of 10 clients who state an intention to commit suicide do so. The more thought-out the plan, the higher the chances of completing it. The chances of suicide increase if there was a previous suicide attempt or if a family 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 times (e.g., during mood changes, at initiation of/ changes in medication regimen, when increasing withdrawal occurs, when discharge planning becomes active, before sending out on pass, before discharge from program).
Rationale: Suicide risk is the greatest during the first few weeks following admission to treatment. More than half of suicides by hospitalized clients occur out of the hospital, while they are on leave or during an unauthorized absence. The highest risk 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, explain to client that you are concerned for his or her safety and that you will be helping client to stay “safe.”
Rationale: Communicates caring and provides sense of protection.
Create a time-specific contract with client on what client and nurse will do to provide for client’s safety. Renew contract as appropriate. Place a copy of the “contract,” signed by client and staff, in the chart/ file and give a copy to the client to keep.
Rationale: Documents actions taken to prevent suicide and client response. It also promotes communication and can help client realize that others care what happens. Short-term contracts encourage client to deal with the here-and-now and provide opportunity to reassess situation.
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.