Nursing Assessment and Care for Patients with MDD

- Nursing assessment and care for patients with MDD involve the following steps:

• Nursing assessment tools: These include standardized scales such as PHQ-9, HAM-D, or BDI to measure the severity and impact of depression on the patient’s functioning. These tools can also help monitor the patient’s progress and response to treatment. Additionally, nurses should assess the patient’s medical history, medication use, substance use, suicidal risk, psychosocial factors, coping skills, and support system.
• Risk assessment for suicide and self-harm: This is a crucial part of nursing care for patients with MDD, as they have a higher risk of suicide than the general population. Nurses should ask direct questions about the patient’s suicidal thoughts, plans, means, intent, and previous attempts. Nurses should also look for warning signs such as hopelessness, isolation, giving away possessions, saying goodbye, etc. Nurses should provide a safe environment for the patient by removing any potential means of self-harm or suicide, such as sharp objects, medications, firearms, etc. Nurses should also implement a suicide prevention plan with the patient that includes identifying triggers, coping strategies, emergency contacts, and follow-up care.
• Developing a therapeutic nurse-patient relationship: This is an essential component of nursing care for patients with MDD, as it can foster trust, rapport, empathy, and communication between the nurse and the patient. Nurses should use active listening skills, open-ended questions, reflective statements, and nonverbal cues to convey interest, respect, and understanding. Nurses should also avoid giving false reassurance, advice, or criticism, as these can undermine the patient’s autonomy and self-efficacy. Nurses should encourage the patient to express their feelings, thoughts, and concerns, and validate their emotions without judgment. Nurses should also provide hope and optimism by highlighting the patient’s strengths, resources, and achievements.
• Pharmacological interventions and nursing considerations: These include administering antidepressant medications as prescribed, monitoring for therapeutic effects and adverse reactions, educating the patient about the medication regimen, and promoting medication adherence. Some of the nursing considerations for pharmacological interventions are:
  • SSRIs: These are the first-line antidepressants for most patients with MDD. They work by blocking the reuptake of serotonin in the synaptic cleft, thereby increasing its availability. Examples of SSRIs are fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). Some of the common side effects of SSRIs are nausea, diarrhea, headache, insomnia, sexual dysfunction, weight gain, and increased bleeding risk. A rare but serious adverse reaction is serotonin syndrome, which is caused by excessive serotonin levels in the brain. Serotonin syndrome can manifest as agitation, confusion, tremor, hyperthermia, tachycardia, hypertension, muscle rigidity, seizures, and coma. Serotonin syndrome can be triggered by taking SSRIs with other serotonergic agents such as MAOIs, TCAs, SNRIs, triptans (migraine medications), St. John’s wort (herbal supplement), etc. Nurses should monitor the patient for signs and symptoms of serotonin syndrome and report them immediately to the prescriber. Nurses should also teach the patient to avoid taking SSRIs with other serotonergic agents or alcohol, to take the medication at the same time every day with food or water, to not stop or change the dose without consulting the prescriber, and to report any side effects or suicidal thoughts.
  • SNRIs: These are another class of antidepressants that work by blocking the reuptake of serotonin and norepinephrine in the synaptic cleft. Examples of SNRIs are venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq), and levomilnacipran (Fetzima). Some of the common side effects of SNRIs are similar to those of SSRIs, such as nausea, diarrhea, headache, insomnia, sexual dysfunction, weight gain, and increased bleeding risk. Additionally, SNRIs can cause increased blood pressure, heart rate, and sweating. A rare but serious adverse reaction is serotonin-norepinephrine syndrome, which is similar to serotonin syndrome but also involves norepinephrine excess. Serotonin-norepinephrine syndrome can be triggered by taking SNRIs with other serotonergic or noradrenergic agents such as MAOIs, TCAs, stimulants, opioids, etc. Nurses should monitor the patient for signs and symptoms of serotonin-norepinephrine syndrome and report them immediately to the prescriber. Nurses should also teach the patient to avoid taking SNRIs with other serotonergic or noradrenergic agents or alcohol, to take the medication at the same time every day with food or water, to not stop or change the dose without consulting the prescriber, and to report any side effects or suicidal thoughts.
  • TCAs: These are an older class of antidepressants that work by blocking the reuptake of serotonin and norepinephrine in the synaptic cleft. Examples of TCAs are amitriptyline (Elavil), nortriptyline (Pamelor), imipramine (Tofranil), desipramine (Norpramin), and clomipramine (Anafranil). Some of the common side effects of TCAs are dry mouth, blurred vision, constipation, urinary retention, drowsiness, dizziness, weight gain, and cardiac arrhythmias. A rare but serious adverse reaction is TCA overdose, which can cause seizures, coma, and death. TCA overdose can be caused by taking too much TCA or by combining TCA with other drugs that increase its levels in the blood such as SSRIs, MAOIs, antihistamines, etc. Nurses should monitor the patient for signs and symptoms of TCA overdose and report them immediately to the prescriber. Nurses should also teach the patient to avoid taking TCAs with other drugs that increase its levels in the blood or alcohol, to take the medication at bedtime to avoid daytime sedation, to not stop or change the dose without consulting the prescriber, and to report any side effects or suicidal thoughts.
  • MAOIs: These are another older class of antidepressants that work by inhibiting the enzyme monoamine oxidase (MAO) that breaks down serotonin, norepinephrine, and dopamine in the brain and other tissues. Examples of MAOIs are phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan), and selegiline (Emsam). Some of the common side effects of MAOIs are insomnia, orthostatic hypotension, weight gain, sexual dysfunction, and headache. A rare but serious adverse reaction is hypertensive crisis, which is caused by a dangerous rise in blood pressure due to the interaction of MAOIs with tyramine, a substance found in certain foods and beverages. Tyramine can cause the release of large amounts of norepinephrine, leading to vasoconstriction and increased cardiac output. Hypertensive crisis can manifest as severe headache, chest pain, palpitations, nausea, vomiting, sweating, etc. Hypertensive crisis can be treated with phentolamine or nifedipine, which are vasodilators that lower blood pressure. Nurses should monitor the patient for signs and symptoms of hypertensive crisis and report them immediately to the prescriber. Nurses should also teach the patient to avoid taking MAOIs with other drugs that increase serotonin or norepinephrine levels in the blood such as SSRIs, SNRIs, TCAs, stimulants, opioids, etc., or alcohol. Nurses should also teach the patient to follow a low-tyramine diet that excludes foods and beverages such as aged cheese, pepperoni, salami, avocados, figs, bananas, smoked fish, protein supplements, beers, red wine, etc.
  • Atypical antidepressants: These are a heterogeneous group of antidepressants that do not fit into the other classes and have different mechanisms of action. Examples of atypical antidepressants are bupropion (Wellbutrin), mirtazapine (Remeron), nefazodone (Serzone), trazodone (Desyrel), and vilazodone (Viibryd). Some of the common side effects of atypical antidepressants are nausea, dry mouth, drowsiness, insomnia, weight changes, sexual dysfunction, and headache. A rare but serious adverse reaction is serotonin syndrome or serotonin-norepinephrine syndrome when taken with other serotonergic or noradrenergic agents. Nurses should monitor the patient for signs and symptoms of these syndromes and report them immediately to the prescriber. Nurses should also teach the patient to avoid taking atypical antidepressants with other drugs that increase serotonin or norepinephrine levels in the blood or alcohol. Nurses should also teach the patient to take the medication as prescribed and to report any side effects or suicidal thoughts.