CRITICAL PATHWAY of Care for the Depressed Client

Estimated length of stay: 14 days-variations from designated pathway should be documented in progress notes.

Nursing Diagnosis and Categories of Care	Time Dimension	Goals/Actions	Time Dimension	Goals/Actions	Time Dimensions	Discharge Outcome
Risk for selfdirected violence	Day 1	Environment safe for client	Ongoing	Client does not harm self.	Day 14	Client is discharged without harm to self.
Referrals	Day 1	Psychiatrist: May give order to isolate if risk is great or may do ECT For relaxation therapy: Music therapist Clinical nurse specialist Stress management specialist			Day 14	Discharge with follow-up appointments required.
Additional assessments	Day 1	Suicidal assessment: Ideations Gestures Threats Plan Means Anxiety level Thought disorder	Day 2-14	Ongoing assessments	Day 14	Client discharged. Denies suicidal idestions.
	Day 1	Secure no-suicide contract
Medications	Day 1	Antidepressant medication, as ordered Antianxiety agents, prn	Day 1-14	Assess for effectiveness and side effects of medications Be alert for sudden lifts in mood.	Day 14	Discharged with antidepressant medications.
Client education	Day 3-12	Teach relaxation techniques Discuss resources outside the hospital from whom client may seek assistance when feeling suicidal	Day 12-13	Reinforce teaching	Day 14	Discharge with understanding of instruction given.
Dysfunctional grieving	Day 1	Assess stage of fixation in grief process			Day 14	Discharge with evidence of progression toward resolution of grief.
Referrals	Day 1	Psychiatrist Psychologist Social worker Clinical nurse specialist Music therapist Occupational therapist Recreational therapist Chaplain			Day 14	Discharge with follow-up appointments required.
Diagnostic studies	Day l Day 2-3	Any of the following tests may be ordered: Drug screen Urine test for norepinephrine and serotonin Dexamethasone suppression test A measure of TSH response to administered TRH Serum and urine studies for nutritional deficiencies
Medications	Day 1	Antidepressant medication, as ordered Antianxiety agent, prn	Day 1-14	Assess for effectiveness and side effects of medications.	Day 14	Client is discharged with medicacations
Diet	Day 1	If antidepressant medication is MAO inhibitor: low tyramine			Day 14	Client has experi- enced no symptoms of hypertensive crisis.
Additional assessments	Day 1	VS every shift Mental status Mood, affect Thought disorder Communication patterns Level of interest in environment Participation in activities Weight	Day 2-14	VS daily if stable. Ongoing assessments	Day 14	Mood and affect appropriate. No evidence of thought disorder. Participates willingly and appropriately in activities
Client education	Dayl	Orient to unit	Day 8	Discuss importance of taking medications regularly even when feeling well or if feeling medication is not helping. Discuss possible side effects of medication and when to see the physician. Teach which foods to eliminate from diet if taking MAO inhibitor.	Day 14	Client is discharged. Verbalizes understanding of information presented before discharge.
			Day 12-13	Reinforce Teaching