Care Plan 25 Major Depressive Disorder

CARE PLAN 25
Major Depressive Disorder
Nursing Diagnosis

Ineffective Coping
Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or
inability to use available resources.

ASSESSMENT DATA
• 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
• Diminished interest in sexual activity
• Fear of intensity of feelings
• Anxiety

EXPECTED OUTCOMES
Immediate
The client will
• Be free from self-inflicted harm throughout hospitalization
• Engage in reality-based interactions within 24 hours
• Be oriented to person, place, and time within 48 to 72 hours
• Express anger or hostility outwardly in a safe manner, for example, talking with staff members within
5 to 7 days
Stabilization
The client will
• Express feelings directly with congruent verbal and nonverbal messages
• Be free from psychotic symptoms
• Demonstrate functional level of psychomotor activity

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25
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
IMPLEMENTATION
Nursing Interventions
* denotes collaborative interventions
Provide a safe environment for the client.
Continually assess the client’s potential for
suicide. 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.
• During unstructured time on the unit or times
when the number of staff on the unit is
limited.
• After any dramatic behavioral change (sudden
cheerfulness, relief, or giving away personal
belongings).
See Care Plan 26: Suicidal Behavior.
Reorient the client to person, place, and time as
indicated (call the client by name, tell the client
your name, tell the client where he or she is, etc.).
Spend time with the client.
If the client is ruminating, tell him or her that you
will talk about reality or about the client’s
feelings, but limit the attention given to repeated
expressions of rumination.
Initially, assign the same staff members to work
with the client whenever possible.
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Major Depressive Disorder
Rationale
Physical safety of the client is a priority. Many
common items may be used in a self-destructive
manner.
Clients with depression may have a potential for
suicide that may or may not be expressed and that
may change with time.
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, when the
client’s time is unstructured, and when observation
of the client decreases. These changes may
indicate that the client has come to a decision to
commit suicide.
Repeated presentation of reality is concrete
reinforcement for the client.
Your physical presence is reality.
Minimizing attention may help decrease
rumination. Providing reinforcement for reality
orientation and expression of feelings will
encourage these behaviors.
The client’s ability to respond to others may be
impaired. Limiting the number of new contacts
initially will facilitate familiarity and trust.
However, the number of people interacting with
the client should increase as soon as possible to
minimize dependency and to facilitate the client’s
abilities to communicate with a variety of people.
Care Plan 25 Major Depressive Disorder

When approaching the client, use a moderate, Being overly cheerful may indicate to the client
level tone of voice. Avoid being overly cheerful. that being cheerful is the goal and that other
feelings are not acceptable.
Use silence and active listening when interacting The client may not communicate if you are talking
with the client. Let the client know that you are too much. Your presence and use of active
concerned and that you consider the client a listening will communicate your interest and
worthwhile person. See Care Plan 45: Withdrawn concern.
Behavior.
Be comfortable sitting with the client in silence. Your silence will convey your expectation that the
Let the client know you are available to converse, client will communicate and your acceptance of
but do not require the client to talk. the client’s difficulty with communication.
When first communicating with the client, use The client’s ability to perceive and respond to
simple, direct sentences; avoid complex complex stimuli is impaired.
sentences or directions.
Avoid asking the client many questions, Asking questions and requiring only brief answers
especially questions that require only brief may discourage the client from expressing
answers. feelings.
Do not cut off interactions with cheerful remarks You may be uncomfortable with certain feelings
or platitudes (e.g., “No one really wants to die,” the client expresses. If so, it is important for you to
or “You’ll feel better soon.”). Do not belittle the recognize this and discuss it with another staff
client’s feelings. Accept the client’s member rather than directly or indirectly
verbalizations of feelings as real, and give communicating your discomfort to the client.
support for expressions of emotions, especially Proclaiming the client’s feelings to be
those that may be difficult for the client (like inappropriate or belittling them is detrimental.
anger).
Encourage the client to ventilate feelings in Expressing feelings may help relieve despair,
whatever way is comfortable—verbal and hopelessness, and so forth. Feelings are not
nonverbal. Let the client know you will listen and inherently good or bad. You must remain
accept what is being expressed. nonjudgmental about the client’s feelings and
express this to the client.
Allow (and encourage) the client to cry. Stay with Crying is a healthy way of expressing feelings of
and support the client if he or she desires. Provide sadness, hopelessness, and despair. The client may
privacy if the client desires and it is safe to do so. not feel comfortable crying and may need
encouragement or privacy.
Interact with the client on topics with which he or Probing or topics that are uncomfortable for the
she is comfortable. Do not probe for information. client may be threatening and discourage
communication. After trust has been established,
the client may be able to discuss more difficult
topics.

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25
Talk with the client about coping strategies he or
she has used in the past. Explore which strategies
have been successful and which may have led to
negative consequences.
Teach the client about positive coping strategies
and stress management skills, such as increasing
physical exercise, expressing feelings verbally or
in a journal, or meditation techniques. Encourage
the client to practice this type of technique while
in the hospital.
Teach the client about the problem-solving
process: explore possible options, examine the
consequences of each alternative, select and
implement an alternative, and evaluate the
results.
Provide positive feedback at each step of the
process. If the client is not satisfied with the
chosen alternative, assist the client to select
another alternative.
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Major Depressive Disorder
The client may have had success using coping
strategies in the past but may have lost confidence
in himself or herself or in his or her ability to cope
with stressors and feelings. Some coping strategies
can be self-destructive (e.g., self-medication with
drugs or alcohol).
The client may have limited or no knowledge of
stress management techniques or may not have
used positive techniques in the past. If the client
tries to build skills in the treatment setting, he or
she can experience success and receive positive
feedback for his or her efforts.
The client may be unaware of a systematic method
for solving problems. Successful use of the
problem-solving process facilitates the client’s
confidence in the use of coping skills.
Positive feedback at each step will give the client
many opportunities for success, encourage him or
her to persist in problem-solving, and enhance
confidence. The client also can learn to “survive”
making a mistake.
Care Plan 25 Major Depressive Disorder

Nursing Diagnosis

Impaired Social Interaction

Insufficient or excessive quantity or ineffective quality of social exchange.

ASSESSMENT DATA
• Withdrawn behavior
• Verbalization diminished in quantity, quality, or spontaneity
• Rumination
• Low self-esteem
• Unsatisfactory or inadequate interpersonal relationships
• Verbalizing or exhibiting discomfort around others
• Social isolation
• Inadequate social skills
• Poor personal hygiene

EXPECTED OUTCOMES
Immediate
The client will
• Communicate with others, for example, respond verbally to question(s) asked by staff within 24 to 48
hours
• Participate in activities within 48 to 72 hours
Stabilization
The client will
• Initiate interactions with others, for example, approach a staff member to talk at least once per shift
• Assume responsibility for dealing with feelings
Community
The client will
• Re-establish or maintain relationships and a social life
• Establish a support system in the community, for example, initiate contacts with others by telephone

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25
IMPLEMENTATION
Nursing Interventions
* denotes collaborative interventions
Initially, interact with the client on a one-to-one
basis. Manage nursing assignments so that the
client interacts with a variety of staff members, as
the client tolerates.
Introduce the client to other clients in the milieu
and facilitate their interactions on a one client to
one client basis. Gradually facilitate social
interactions between the client and small groups,
then larger groups.
Talk with the client about his or her interactions
and observations of interpersonal dynamics.
Teach the client social skills, such as approaching
another person for an interaction, appropriate
conversation topics, and active listening.
Encourage him or her to practice these skills with
staff members and other clients, and give the
client feedback regarding interactions.
Encourage the client to identify relationships,
social, or recreational situations that have been
positive in the past.
*Encourage the client to pursue past
relationships, personal interests, hobbies, or
recreational activities that were positive in the
past or that may appeal to the client. Consultation
with a recreational therapist may be indicated.
*Encourage client to identify supportive people
outside the hospital and to develop these
relationships.
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Major Depressive Disorder
Rationale
Your social behavior provides a role model for the
client. Interacting with different staff members
allows the client to experience success in
interactions within the safety of the staff–client
relationship.
Gradually increasing the scope of the client’s
social interactions will help the client build
confidence in social skills.
Awareness of interpersonal and group dynamics is
an important part of building social skills. Sharing
observations provides an opportunity for the client
to express his or her feelings and receive feedback
about his or her progress.
The client may lack social skills and confidence in
social interactions; this may contribute to the
client’s depression and social isolation.
The client may have been depressed and
withdrawn for some time and have lost interest in
people or activities that provided pleasure in the
past.
The client may be reluctant to reach out to
someone with whom he or she has had limited
contact recently and may benefit from
encouragement or facilitation. Recreational
activities can serve as a structure for the client to
build social interactions as well as provide
enjoyment.
In addition to re-establishing past relationships or
in their absence, increasing the client’s support
system by establishing new relationships may help
decrease future depressive behavior and social
isolation.
Care Plan 25 Major Depressive Disorder

Nursing Diagnosis

Bathing Self-Care Deficit

Impaired ability to perform or complete bathing activities for self.

Dressing Self-Care Deficit

Impaired ability to perform or complete dressing activities for self.

Feeding Self-Care Deficit

Impaired ability to perform or complete self-feeding activities.

Toileting Self-Care Deficit

Impaired ability to perform or complete toileting activities for self.

ASSESSMENT DATA
• Anergy (overall lack of energy for purposeful activity)
• Decreased motor activity
• Lack of awareness or interest in personal needs
• Self-destructive feelings
• Withdrawn behavior
• Psychological immobility
• Disturbances of appetite or regular eating patterns
• Fatigue

EXPECTED OUTCOMES
Immediate
The client will
• Establish adequate nutrition, hydration, and elimination with nursing assistance within 2 to 4 days
• Establish an adequate balance of rest, sleep, and activity with nursing assistance within 2 to 4 days
• Establish adequate personal hygiene, for example, tolerate bathing and grooming as assisted by staff
within 24 to 48 hours
Stabilization
The client will
• Maintain adequately balanced physiologic functioning
• Maintain adequate personal hygiene independently, for example, follow structured routine for bathing
and hygiene, initiate self-care activities
Community
The client will
• Maintain a daily routine that meets physiologic and personal needs, including nutrition, hydration,
elimination, hygiene, sleep, activity

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25
IMPLEMENTATION
Nursing Interventions
* denotes collaborative interventions
Closely observe the client’s food and fluid intake.
Record intake, output, and daily weight if
necessary.
Offer the client foods that are easily chewed,
fortified liquids such as nutritional supplements,
and high-protein malts.
Try to find out what foods the client likes,
including culturally based or foods from family
members, and make them available at meals and
for snacks.
Do not tell the client that he or she will get sick
or die from not eating or drinking.
If the client is overeating, limit access to food,
schedule meals and snacks, and serve limited
portions. Give the client positive feedback for
adhering to the prescribed diet.
Observe and record the client’s pattern of bowel
elimination.
Encourage good fluid intake.
Be aware of PRN laxative orders and the possible
need to offer medication to the client.
Provide the client with his or her own clothing
and personal grooming items when possible.
Initiate dressing and grooming tasks in the
morning.
Maintain a routine for dressing, grooming, and
hygiene.
The client may need physical assistance to get up,
dress, and spend time on the unit.
Be gentle but firm in setting limits regarding time
spent in bed. Set specific times when the client
must be up in the morning, and when and for how
long the client may rest.
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Major Depressive Disorder
Rationale
The client may not be aware of or interested in
meeting physical needs, but these needs must be
met.
If the client lacks interest in eating, highly
nutritious foods that require little effort to eat may
help meet nutritional needs.
The client may be more apt to eat foods he or she
likes or has been accustomed to eating.
The client may hope to become ill or die from not
eating or drinking.
The client may need limits to maintain a healthful
diet.
Severe constipation may result from the
depression; inadequate exercise, food, or fluid
intake; or the effects of some medications.
Constipation may result from inadequate fluid
intake.
The client may be unaware of constipation and
may not ask for medication.
Familiar items will decrease the client’s confusion
and promote task completion.
Clients with depression may have the most energy
and feel best in the morning and may have greater
success at that time.
A routine eliminates needless decision making,
such as whether or not to dress or perform
personal hygiene.
The client’s ability to arise, initiate activity, and
join in the milieu is impaired.
Specific limits let the client know what is expected
and indicate genuine caring and concern for the
client.
Care Plan 25
Provide a quiet, peaceful time for resting.
Decrease environmental stimuli (conversation,
lights) in the evening.
Provide a nighttime routine or comfort measures
(back rub, tepid bath, warm milk) just before
bedtime.
Talk with the client for only brief periods during
night hours to help alleviate anxiety and to
provide reassurance before the client returns to
bed.
Do not allow the client to sleep for long periods
during the day.
Use PRN medications as indicated to facilitate
sleep. Note: Some sleep medications may worsen
depression or cause agitation.
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Major Depressive Disorder
Limiting noise and other stimuli will encourage
rest and sleep.
Use of a routine may help the client expect to
sleep.
Talking with the client for long periods during the
night will stimulate the client, give the client
attention for not sleeping, and interfere with the
client’s sleep.
Sleeping excessively during the day may decrease
the client’s need for and ability to sleep at night.
Medications may be helpful in facilitating sleep.
Care Plan 25 Major Depressive Disorder

Nursing Diagnosis

Chronic Low Self-Esteem

Longstanding negative self-evaluating/feelings about self or self-capabilities.

ASSESSMENT DATA
• Feelings of inferiority
• Defeatist thinking
• Self-criticism
• Lack of involvement
• Minimizing of own strengths
• Guilt
• Feelings of despair, worthlessness

EXPECTED OUTCOMES
Immediate
The client will
• Verbalize increased feelings of self-worth within 2 to 5 days
• Express feelings directly and openly with nursing facilitation within 2 to 4 days
• Evaluate own strengths realistically, for example, describe three areas of personal strength, with
nursing assistance, within 2 to 4 days
Stabilization
The client will
• Demonstrate behavior consistent with increased self-esteem, for example, make eye contact, initiate
conversation or activity with staff or other clients
• Make plans for the future consistent with personal strengths
Community
The client will
• Express satisfaction with self and personal qualities

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Care Plan 25
IMPLEMENTATION
Nursing Interventions
* denotes collaborative interventions
Encourage the client to become involved with
staff and other clients in the milieu through
interactions and activities.
Give the client positive feedback for completing
responsibilities and interacting with others.
If negativism dominates the client’s
conversations, it may help to structure the content
of interactions, for example, by making an
agreement to listen to 10 minutes of “negative”
interaction, after which the client will interact on
a positive topic.
Explore with the client his or her personal
strengths. Making a written list is sometimes
helpful.
Involve the client in activities that are pleasant or
recreational as a break from self-examination.
*At first, provide simple activities that can be
accomplished easily and quickly. Begin with a
solitary project; progress to group occupational
and recreational therapy sessions. Give the client
positive feedback for participation.
It may be necessary to stress to the client that he
or she should begin doing things to feel better,
rather than waiting to feel better before doing
things.
Give the client honest praise for accomplishing
small responsibilities by acknowledging how
difficult it can be for the client to perform these
tasks.
Gradually increase the number and complexity of
activities expected of the client; give positive
feedback at each level of accomplishment.
From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition.
© Wolters Kluwer Health | Lippincott Williams & Wilkins.
Major Depressive Disorder
Rationale
When the client can focus on other people or
interactions, cyclic, negative thoughts are
interrupted.
Positive feedback increases the likelihood that the
client will continue the behavior and begin to
internalize positive feelings, such as the
satisfaction of completing a task successfully.
The client will feel you are acknowledging his or
her feelings yet will begin practicing the conscious
interruption of negativistic thought and feeling
patterns.
While you can help the client discover his or her
strengths, it will not be useful for you to list the
client’s strengths. The client needs to identify
them but may benefit from your supportive
expectation that he or she will do so.
The client needs to experience pleasurable
activities that are not related to self and problems.
Such experiences can demonstrate the usefulness
of incorporating leisure activities into his or her
life.
The client may be limited in his or her ability to
deal with complex tasks or stimuli. Any task that
the client is able to complete provides an
opportunity for positive feedback to the client.
The client will have the opportunity to recognize
his or her own achievements and will receive
positive feedback. Without this stimulus, the client
may lack motivation to attempt activities.
Clients with low self-esteem do not benefit from
flattery or undue praise. Positive feedback
provides reinforcement for the client’s growth and
can enhance self-esteem.
As the client’s abilities increase, he or she can
accomplish more complex activities and receive
more feedback.