DEPRESSIVE DISORDERS

SOCIAL ISOLATION/IMPAIRED SOCIAL INTERACTION

Definition: Social isolation is the condition of aloneness experienced by the individual
and perceived as imposed by others and as a negative or threatened state; impaired
social interaction is the state in which an individual participates in an insufficient or
excessive quantity or ineffective quality of social exchange.

Possible Etiologies ("related to")

[Developmental regression]
[Egocentric behaviors (which offend others and discourage relationships)]
Disturbed thought processes [delusional thinking]
[Fear of rejection or failure of the interaction]
[Impaired cognition fostering negative view of self]
[Unresolved grief]
Absence of available significant others or peers

Defining Characteristics ("evidenced by")

Sad, dull affect
Being uncommunicative, withdrawn; lacking eye contact
Preoccupation with own thoughts; performance of repetitive, meaningless actions
Seeking to be alone
[Assuming fetal position]
Expression of feelings of aloneness or rejection
Verbalization or observation of discomfort in social situations
Dysfunctional interaction with peers, family, and others

Goals/Objectives

Short-Term Goal

Client will develop trusting relationship with nurse or counselor within reasonable period
of time.

Long-Term Goals

1. Client will voluntarily spend time with other clients and nurse or therapist in group
activities by discharge from treatment.

2. Client will refrain from using egocentric behaviors that offend others and
discourage relationships by discharge from treatment.

Interventions with Selected Rationales

1. Spend time with client. This may mean just sitting in silence for a while. Your
presence may help improve client's perception of self as a worthwhile
person.
2. Develop a therapeutic nurse-client relationship through frequent, brief contacts
and an accepting attitude. Show unconditional positive regard. Your presence,
acceptance, and conveyance of positive regard enhance the client's
feelings of self-worth.
3. After client feels comfortable in a one-to-one relationship, encourage attendance in
group activities. May need to attend with client the first few times to offer support.
Accept client's decision to remove self from group situation if anxiety becomes too
great. The presence of a trusted individual provides emotional security for
the client.
4. Verbally acknowledge client's absence from any group activities. Knowledge that
his or her absence was noticed may reinforce the client's feelings of self-
worth.
 5. Teach assertiveness techniques. Interactions with others may be negatively
affected by client's use of passive or aggressive behaviors. Knowledge of
assertive techniques could improve client's relationships with others.
6. Provide direct feedback about client's interactions with others. Do this in a
nonjudgmental manner. Help client learn how to respond more appropriately in
interactions with others. Teach client skills that may be used to approach others in
a more socially acceptable manner. Practice these skills through role play. Client
may not realize how he or she is being perceived by others. Direct
feedback from a trusted individual may help alter these behaviors in a
positive manner. Practicing these skills in role play facilitates their use in
real situations.
7. The depressed client must have a lot of structure in his or her life because of
impairment in decision-making and problem-solving ability. Devise a plan of
therapeutic activities and provide client with a written time schedule. Remember:
The client who is moderately depressed feels best early in the day, whereas the
severely depressed individual feels better later in the day; choose these times for
the client to participate in activities.
8. Provide positive reinforcement for client's voluntary interactions with others.
Positive reinforcement enhances self-esteem and encourages repetition
of desirable behaviors.

Outcome Criteria

1. Client demonstrates willingness and desire to socialize with others.

2. Client voluntarily attends group activities.
3. Client approaches others in appropriate manner for one-to-one interaction.

INEFFECTIVE COPING
Definition: Inability to form a valid appraisal of the stressors, inadequate choices of
practiced responses, and/or inability to use available resources.

Possible Etiologies ("related to")

Situational crises
Maturational crises
[Inadequate support systems]
[Negative role modeling]
[Retarded ego development]
[Fixation in earlier level of development]
[Dysfunctional family system]
[Low self-esteem]
[Unresolved grief]

Defining Characteristics ("evidenced by")

Inability to meet role expectations
[Alteration in societal participation]
Inadequate problem solving
[Increased dependency]
[Manipulation of others in the environment for purposes of fulfilling own desires]
[Refusal to follow rules]

Goals/Objectives

Short-Term Goal

By the end of 1 week, client will comply with rules of therapy and refrain from
manipulating others to fulfill own desires.

Long-Term Goal

By discharge from treatment, client will identify, develop, and use socially acceptable
coping skills.
Interventions with Selected Rationales

1. Discuss with client the rules of therapy and the consequences of noncompliance.
Carry out the consequences matter of factly if rules are broken. Negative
consequences may decrease manipulative behaviors.

2. Do not debate, argue, rationalize, or bargain with the client regarding limit setting
on manipulative behaviors. Ignoring these attempts may decrease
manipulative behaviors. Consistency among all staff members is vital if
this intervention is to be successful.

3. Encourage discussion of angry feelings. Help client identify the true object of the
hostility. Provide physical outlets for healthy release of the hostile feelings (e.g.,
punching bags, pounding boards). Verbalizing feelings with a trusted
individual may help client work through unresolved issues. Physical
exercise provides a safe and effective means of releasing pent-up
tension.

4. Take care not to reinforce dependent behaviors. Encourage client to perform as

independently as possible and provide positive feedback. Independent
accomplishment and positive reinforcement enhance self-esteem and
encourage repetition of desirable behaviors.

5. Help client recognize some aspects of his or her life over which a measure of
control is maintained. Recognition of personal control, however minimal,
diminishes the feeling of powerlessness and decreases the need for
manipulation of others.

6. Identify the stressor that precipitated the maladaptive coping. If a major life
change has occurred, encourage client to express fears and feelings associated
with the change. Assist client through the problem-solving process:
a. Identify possible alternatives that indicate positive adaptation.
b. Discuss benefits and consequences of each alternative.
c. Select the most appropriate alternative.
d. Implement the alternative.
e. Evaluate the effectiveness of the alternative.
f. Recognize areas of limitation and make modifications. Request assistance
with this process, if needed.

7. Provide positive reinforcement for application of adaptive coping skills and

evidence of successful adjustment. Positive reinforcement enhances self-
esteem and encourages repetition of desirable behaviors.

Outcome Criteria

1. Client is able to verbalize alternative, socially acceptable, and lifestyle-appropriate

coping skills he or she plans to use in response to stress.
2. Client is able to solve problems and independently fulfill activities of daily living.
3. Client does not manipulate others for own gratification.

RISK FOR VIOLENCE: SELF-DIRECTED OR OTHER-DIRECTED

Definition: Behaviors in which an individual demonstrates that he or she can be
physically, emotionally, and/or sexually harmful to self or to others.

Related/Risk Factors ("related to")

[Fixation in earlier level of development]
[Negative role modeling]
[Dysfunctional family system]
[Low self-esteem]
[Unresolved grief]
[Psychic overload]
[Extended exposure to stressful situation]
[Lack of support systems]
[Biological factors, such as organic changes in the brain]
Body language---rigid posture, clenching of fists and jaw, hyperactivity, pacing,
breathlessness, and threatening stances
History or threats of violence toward self or others or of destruction to property of others
Impulsivity
Suicidal ideation, plan, available means
[Anger; rage]
[Increasing anxiety level]
[Depressed mood]

Goals/Objectives

Short-Term Goals

1. Client will seek out staff member when hostile or suicidal feelings occur.
2. Client will verbalize adaptive coping strategies to use when hostile or suicidal
feelings occur.

Long-Term Goals

1. Client will demonstrate adaptive coping strategies to use when hostile or suicidal
feelings occur.
2. Client will not harm self or others.

Interventions with Selected Rationales

1. Observe client's behavior frequently. Do this through routine activities and

interactions; avoid appearing watchful and suspicious. Close observation is
required so that intervention can occur if required to ensure client's (and
others') safety.
2. Observe for suicidal behaviors: verbal statements, such as "I'm going to kill
myself'" and "Very soon my mother won't have to worry herself about me any
longer," and nonverbal behaviors, such as mood swings and giving away cherished
items. Clients who are contemplating suicide often give clues regarding
their potential behavior. The clues may be very subtle and require keen
assessment skills on the part of the nurse.
3. Determine suicidal intent and available means. Ask direct questions, such as "Do
you plan to kill yourself?" and "How do you plan to do it?" The risk of suicide is
greatly increased if the client has developed a plan and particularly if the
client has means to execute the plan.
4. Obtain verbal or written contract from client agreeing not to harm self and to seek
out staff if suicidal ideation occurs. Discussion of suicidal feelings with a
trusted individual provides a degree of relief to the client. A contract
gets the subject out in the open and places some of the responsibility for
his or her safety with the client. An attitude of acceptance of the client
as a worthwhile individual is conveyed.
5. Assist client to recognize when anger occurs and to accept those feelings as his or
her own. Have client keep an "anger notebook," in which feelings of anger
experienced during a 24-hour period are recorded. Information regarding source of
anger, behavioral response, and client's perception of the situation should also be
noted. Discuss entries with client and suggest alternative behavioral responses for
responses identified as maladaptive.
6. Act as a role model for appropriate expression of angry feelings and give positive
reinforcement to client for attempting to conform. It is vital that the client
express angry feelings because suicide and other self-destructive
behaviors are often viewed as the result of anger turned inward onthe
self.
 7. Remove all dangerous objects from client's environment (e.g., sharp items, belts,
ties, straps, breakable items, smoking materials). Client safety is a nursing
priority.
8. Try to redirect violent behavior with physical outlets for the client's anxiety (e.g.,
punching bag, jogging). Physical exercise is a safe and effective way of
relieving pent-up tension.
9. Be available to stay with client as anxiety level and tensions begin to rise. The
presence of a trusted individual provides a feeling of security and may
help prevent rapid escalation of anxiety.
10. Staff should maintain and convey a calm attitude to client. Anxiety is contagious
and can be transmitted from staff members to client.
11. Have sufficient staff available to indicate a show of strength to client if necessary.
This conveys to the client evidence of control over the situation and
provides some physical security for staff.
12. Administer tranquilizing medications as ordered by physician or obtain an order if
necessary. Monitor client response for effectiveness of the medication and for
adverse side effects. Tranquilizing medications, such as anxiolytics and
antipsychotics, are capable of inducing a calming effect on the client and
may prevent aggressive behaviors.
13. Use of mechanical restraints or isolation room may be required if less
restrictive interventions are unsuccessful. Follow policy and procedure prescribed
by the institution in executing this intervention. The Joint Commission on
Accreditation of Healthcare Organizations requires that the physician issue a new
order for restraints every 4 hours for adults and every 1 to 2 hours for children and
adolescents. If the client has previously refused medication, administer it after
restraints have been applied. Most states consider this intervention appropriate in
emergency situations or in situations in which a client would likely harm self or
others.
14. Observe the client in restraints every 15 minutes (or according to institutional
policy). Ensure that circulation to extremities is not compromised (check
temperature, color, pulses). Assist client with needs related to nutrition, hydration,
and elimination. Position client so that comfort is facilitated and aspiration can be
prevented. Client safety is a nursing priority.
15. As agitation decreases, assess client's readiness for restraint removal or reduction.
Remove one restraint at a time, while assessing client's response. This minimizes
risk of injury to client and staff.

Outcome Criteria

1. Anxiety is maintained at a level at which client feels no need for aggression.

2. Client denies any ideas of self-destruction.
3. Client demonstrates use of adaptive coping strategies when feelings of hostility or
suicide occur.
4. Client verbalizes community support systems from whom assistance may be
requested when personal coping strategies are not successful.