Patients seem depressed: What should nurses do?
Teach staff to identify symptoms
A patient has begun to lose weight, and the home care aide reports that he only picks at his food and sometimes refuses to eat altogether. The nurse also notes that the patient says he can’t sleep through the night, and he hasn’t been taking his medication correctly.
The nurse might suspect the patient is depressed, but if this assumption is correct, how should the home care agency handle the situation? The VNA of Fox Valley in Aurora, IL, has a nursing program that answers this important question through a psychiatric support structure and a staff education program.
"We have 10 full-time psychiatric nurses, and if a medical nurse identifies symptoms of depression that are not related to medication, then the psychiatric nurse goes into the home and does a mental health assessment," says Darlene Varney, RNC, BSN, mental and behavioral health coordinator of the VNA of Fox Valley, a nonprofit, full service agency that serves the suburbs west of Chicago.
The psychiatric nurse interviews patients using a psychiatric tool, and the nurse evaluates whether patients are safe at home and able to care for themselves.
"We try to do it in a noninterrogative style and more in a conversational style," Varney explains.
Then the nurse tells the physician the findings and typically gives a recommendation based on what’s found. The recommendation usually includes home visits and treatment by the psychiatric nurse.
"We might work with the physician to get the patient on an antidepressant, if necessary, and we provide a whole range of treatment in the home," she says.
Other home care agencies could teach nurses about four of the major methods to treat depression, using tips from VNA of Fox Valley. Here are the methods:
1. Assertiveness training.
Teach patients how to get their needs met without hurting the feelings of family members or alienating other people. "You can start with teaching patients how to use I statements, as in a capital I, because they’re not used to standing up for themselves," Varney says. "So many times they’re allowing other people to tell them what to do, and they’re unhappy and maybe depressed about it."
Another technique is to help patients identify their feelings and tell dominating family members or others how they feel without putting anyone on the defensive. For example, Varney suggests, teach the patient how to make statements such as, "I get angry when you tell me to go to bed I’m not a child," instead of those such as, "You’re always bossing me around." The second statement is more likely to cause conflict.
Varney also advises teaching patients how to ask other people for what they want. "Often the elderly are passive, and they say to people, Anytime you have time, come and take me to the store,’" she says. "We teach them to say, I need to go to the store on Friday because I need food for the weekend,’ and they’re more likely to get what they need this way."
One teaching method she recommends is to have the nurse role-play with the patient. The nurse could pretend to be the patient’s daughter, for example. "Then tell the patient, Tell me what you need,’" Varney says. "Patients will get it wrong a few times, and then we give them a lot of reinforcement when they do it right."
Next, the nurse can teach the patient how to deal with conflict. Varney has found that many elderly people were raised to believe it isn’t polite to have a disagreement, so when they’re angry, they won’t say so. "They’ll just bury it," she says.
"We teach them how to be in a conflict and survive it by telling people how they’re feeling and what they need," she says. Also, she adds, ask patients to think about what might happen if they don’t get what they need.
2. Relaxation therapy.
Teach patients how to put themselves in a comfortable setting that reduces stress. Relaxing music or sounds, such as an ocean soundtrack, can help. Other often-used techniques include slow, conscious breathing and visualization or mediation.
VNA of Fox Valley gives patients a four-page instructional book that lists several relaxation techniques. "If someone has had an anxiety attack, we tell them that maybe that’s a time when they want to use the relaxation technique," Varney says.
3. Cognitive therapy.
Help patients recognize thought patterns that make them feel worse about themselves. "We just teach them that before you have a feeling, you have a thought, and we help them to identify some patterns in which they have a certain thought that has caused them to have certain feelings that get them in trouble," Varney relates. One example of these "cognitive distortions" is black and white thinking, such as "You’re either my friend or you’re my enemy."
"Maybe we gave the patient a new homemaker, and the first time the homemaker was supposed to come, she was late," Varney says. "And so the thought the patient has is, You’re not going to get a second chance, and you were late, so you’re my enemy.’"
Also, Varney suggests nurses talk with patients about the most common cognitive distortions that everyone uses. These include:
• making everything awful or always turning little things into big things;
• labeling or stereotyping people;
• prejudging a situation or deciding a meeting with a family member or friend will result in conflict before the meeting takes place;
• overgeneralizing "If one man wasn’t nice to me, then all men are bad";
• mind-reading "I can tell just by the way that person is looking at me what he’s thinking";
• denial refusing to see what’s going on in a given situation;
• should statements "My son should see me everyday";
• discounting the positives "If you tell someone, You really look pretty today,’ the person says, I don’t look pretty, actually, and I really hate this dress’";
• blaming saying others are always wrong no matter what they did.
4. Reality orientation.
Give patients cues to what day and time it is. "A lot of times the elderly sit in a chair and look at TV all day, and after five or six days, they lose track of what day it is," Varney says. Nurses can prevent this time disorientation, she says, by having the patient’s family put a large clock and calendar by the patient’s chair. Also, the nurse, aide, or family can assist the patient in crossing off days and talking about which day of the week it is.
"Do not assume they know what day it is," she says. "Talk about how today’s Monday, and Monday’s the day your home health aide comes in to give you your bath."
[Editor’s note: VNA of Fox Valley has created some critical pathways, including one for mental illness, that the agency sells to other agencies. For more information, call (630) 978-2532 or write to VNA of Fox Valley, 1245 Corporate Blvd., Aurora, IL 60504.]
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