- Hopelessness related to social Isolation and depressed cognitive functions (thinking, decision making) as evidenced by verbalized belief that nothing can be changed and no reason to do so passivity and no response to positive or negative stimuli
- Risk For Suicide related to feelings of hopelessness and history of previous suicide attempt as evidenced by Stockpiling medications and Threats to kill oneself or a desire to die
- Self-Care Deficit related to Insomnia or oversleeping and severe fatigue as evidenced by Poor appearance, body odor, disheveled clothing and Cluttered or messy living environment
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Verbalize that he is fed up with the life Objective Data: -Fatigue -Feeling of sadness and emptiness | Hopelessness related to social Isolation and depressed cognitive functions (thinking, decision making) as evidenced by verbalized belief that nothing can be changed and no reason to do so Passivity and no response to positive or negative stimuli | Patient will verbalize their feelings regarding hopelessness Patient will identify coping mechanisms to improve feelings of hopelessness Patient will set short and long-term goals to develop and maintain a positive outlook | 1. Build a trusting relationship. A trusting, supportive rapport will allow the patient a safe space to address their thoughts and feelings. 2. Help the patient recognize their control. The patient may have a skewed understanding of what is or isn’t in their control. Help the patient recognize misconceptions and accept only what is within their ability to change. 3. Encourage counseling/therapy. Major depression requires the interventions of a trained mental health professional. Psychologists can help with acceptance and adaption to life changes, help set realistic goals and help develop skills to cope. 4. Help identify positive coping behaviors. Assist the patient in identifying coping behaviors they have used in the past that were effective or activities they once enjoyed that can help now. Examples include journaling, music, dance, sports, traveling, spending time outside, or playing with a pet. 5. Refer to a mental health professional. Long-term hopelessness may lead to depression and require intervention from a specialist to uncover deeper issues and assist the patient in coping and learning strategies to manage their problem. 6. Encourage group activities. Patients who feel isolated or abandoned may be reluctant to interact with others but simply being in the presence of others can lift spirits and connecting with the right people can bring a sense of hope and ease loneliness. 7. Incorporate self-care techniques. Determine what the patient likes to do to improve their mood and help them create it. Journaling can help with reflection and expressing feelings. Assist the patient to get outside and spend time in nature and sunlight. | Patient incorporated coping mechanisms to counteract feelings of hopelessness. Patient recognized and verbalize thoughts and feelings with a trusted individual. Patient participated in care that is within their control (ADLs, making small decisions). Patient developed short-term goals to foster a positive outlook. |
| Subjective Data: -Verbalize that feeling to die Objective Data: -Lack of involvement in care -Lack of motivation -Loss of interest in life -Passivity, decreased verbalization -Turning away from the speaker | Risk For Suicide related to feelings of hopelessness and history of previous suicide attempt as evidenced by Stockpiling medications and Threats to kill oneself or a desire to die | Patient will remain safe from suicide or self-injury Patient will identify factors contributing to thoughts of suicide Patient will participate in therapy sessions and willingly attempt to change depression symptoms | 1. Perform screening for suicidal ideations. A variety of suicidal ideation screening and suicide risk assessment scales have been validated and meet the Joint Commission’s requirement for primary care, emergency department, and behavioral health professionals to assess individuals with behavioral health issues. Tools should be consistent with the client’s age, the setting, and organizational policies. 2. Identify characteristics or behaviors pertaining to suicidal ideations. Ask the client questions to elicit thoughts on living and dying. Distinguishing between passive and active suicidal ideation is typically done to identify if there is an imminent short-term risk. The nature of suicidal ideations can fluctuate rapidly, so assessing worst-ever and more recent fluctuations is advised. 3. Assess for early signs of distress or anxiety and investigate possible causes. Anxiety in all its forms leads to a risk of suicide; the constant sense of dread and tension proves unbearable for some. In addition to suicide inquiry, the potential for homicide inquiry must be assessed. Aggression turned inward is suicide; aggression turned outward is homicide. 4. Monitor for suicidal or homicidal ideation. These are indicators of the need for further assessment and intervention or psychiatric care. Determine whether the client has any thoughts of hurting themself. Suicidal ideation is highly linked to completed suicide. 5. Assess suicidal intent on a scale of 0 to 10 or by asking directly if the client is thinking of killing themself, or has plans, means, and so on. This provides guidelines for the necessity and urgency of interventions. Direct questioning is most helpful when done in a caring and concerned manner. 6. Maintain straightforward communication and assist the client to learn assertive rather than manipulative or aggressive behavior. This avoids reinforcing manipulative behavior and enhances positive interactions with others, accomplishing the goal of getting needs met in acceptable ways. The nurse must be clear and consistent with boundaries, expectations, and limitations. The client must understand that the staff is there to support them but that they will not tolerate manipulation, threats, or abusive behavior. 7. Help the client choose activities to redirect their emotions. This promotes the release of energies in acceptable ways. Redirecting a confused client can minimize the escalation of agitation. Using an effective coping strategy such as a task-focused coping style helps the client to think less about suicide. 8. Acknowledge the reality of suicide or homicide as an option. Discuss the consequences of actions if the client were to follow through on their intent. The client may focus on suicide, or possibly homicide, as the “only” option, and this response provides an opening to look at and discuss other options. For any decision, most people naturally weigh the costs and benefits of the potential action. | The client established a safety plan with the nurse, including the identification of triggers, coping strategies, and emergency contacts. The client actively engaged in individual or group therapy sessions to develop new coping skills and strategies. The client maintained regular appointments with a crisis counselor or mental health professional for ongoing support. The client identified at least one meaningful goal for the future, fostering a sense of purpose and hope. The client adhered to a no-suicide contract and verbalize a desire to live. The client engaged in crisis family counseling to address underlying family dynamics and promote a supportive environment. The client demonstrated improved emotional regulation and employ at least two healthy strategies for managing emotional pain. The client recognized their self-worth and identify personal roles and responsibilities in life. The client exhibited a reduction in self-destructive behaviors through the implementation of healthier coping mechanisms. |
| Subjective Data: -Lack of motivation -Lack of energy Objective Data: Poor Hygienic practices | Self-Care Deficit related to Insomnia or oversleeping and severe fatigue as evidenced by Poor appearance, body Odor, dishevelled clothing and cluttered or messy living environment | Patient will bathe at least every other day and dress in clean clothing daily Patient will drink at least 5 glasses of water and eat 2-3 nutritious meals daily Patient will improve sleep habits by instituting a set bedtime and wake time | 1. Encourage and coach. A patient with depression has a slower, clouded thought process and difficulty concentrating. They may need step-by-step guidance to complete even simple tasks. 2. Provide a routine and schedule. Setting a specific sleep/wake schedule and routine for eating, grooming, and dressing can help motivate the patient. 3. Eat with others. Encourage the patient to eat with family and friends or other patients if applicable to increase socialization. 4. Provide nutritious snacks, meals, and fluids. The patient with depression may lack an appetite and the energy to prepare meals. Ensure the patient is drinking plenty of water and provide nutritious snacks such as fruit, nut butters, yogurt, or granola that are easily accessible with minimal preparation. | Patient performed ADLs within their own level of ability. Patient maintained independence with [specify ADL]. Caregiver demonstrated the ability to meet patient’s personal needs. Patient demonstrated appropriate use of adaptive equipment where necessary. |