Preadministration Assessment

A patient receiving an antidepressant drug may be treated in the hospital or in an outpatient setting. Before starting therapy for the hospitalized patient, the nurse obtains a complete medical history. The nurse assesses the patient's mental status to determine the degree of depression and to obtain a baseline for comparison with future assessments (Fig. 31-1). The patient may report feelings of anxiety, worthlessness, guilt, helplessness, and hopelessness. The nurse documents any subjective


This is a questionnaire. On the questionnaire are groups of statements. Please read the entire group of statements in each category. Then pick out the one statement in that group that best describes the way you feel today, that is, right now! Circle the number beside the statement you have chosen. If several statements in the group seem to apply equally well, circle each one.

Be sure to read all the statements in each group before making your choice.


3 I am so sad or unhappy that I can't stand it.

2 I am blue or sad all the time and I can't snap out of it.

1 I feel sad or blue.

0 I do not feel sad.

B. Pessimism

3 I feel that the future is hopeless and that things cannot improve.

2 I feel I have nothing to look forward to.

1 I feel discouraged about the future.

0 I am not particularly pessimistic or discouraged about the future.

C. Sense of failure

3 I feel I am a complete failure as a person (parent, husband, wife).

2 As I look back on my life, all I can see is a lot of failures.

1 I feel I have failed more than the average person.

0 I do not feel like a failure.

D. Dissatisfaction

3 I am dissatisfied with everything.

2 I don't get satisfaction out of anything anymore.

1 I don't enjoy things the way I used to.

0 I am not particularly dissatisfied.

E. Guilt

3 I feel as though I am very bad or worthless.

2 I feel quite guilty.

1 I feel bad or unworthy a good part of the time.

0 I don't feel particularly guilty.

F. Self-dislike

3 I hate myself.

2 I am disgusted with myself.

1 I am disappointed in myself.

0 I don't feel disappointed in myself.

G. Self-harm

3 I would kill myself if I had the chance.

2 I have definite plans about committing suicide.

1 I feel I would be better off dead.

0 I don't have any thought of harming myself.

H. Social withdrawal

3 I have lost all of my interest in other people and don't care about them at all.

2 I have lost most of my interest in other people and have little feeling for them.

1 I am less interested in other people than I used to be.

0 I have not lost interest in other people.

I. Indecisiveness

3 I can't make any decisions at all anymore.

2 I have great difficulty in making decisions.

1 I try to put off making decisions.

0 I make decisions about as well as ever.

J. Self-image change

3 I feel that I am ugly or repulsive-looking.

2 I feel that there are permanent changes in my appearance and they make me look unattractive.

1 I am worried that I am looking old or unattractive. 0 I don't feel that I look any worse than I used to.

K. Work difficulty

2 I have to push myself very hard to do anything.

1 It takes extra effort to get started at doing something.

0 I can work about as well as before.

L. Fatigability

3 I get too tired to do anything.

2 I get tired from doing anything.

1 I get tired more easily than I used to.

0 I don't get any more tired than usual.

M. Anorexia

3 I have no appetite at all anymore.

2 My appetite is much worse now.

1 My appetite is not as good as it used to be. 0 My appetite is no worse than usual.

: None or minimal depression Mild depression Moderate depression : Severe depression

Figure 31-1. Beck Depression Inventory, Short Form. (From Beck, A. T., Ward, C. H., Mendelson, M., et al. [1961]. An inventory for measuring depression. Archives of General Psychiatry4\561-57. Copyright 1961. American Medical Association. Used with permission.)

feelings as well as slowness to answer questions, a monotone speech pattern, and any sadness or crying.

It is important for the nurse to note the presence of suicidal thoughts. The nurse accurately documents in the patient's record and reports to the primary health care provider any statements concerning suicide and the ability of the patient to carry out any suicide intentions. The nurse performs a physical assessment, which includes obtaining blood pressure measurements on both arms with the patient in a sitting position, pulse, respiratory rate, and weight.

The preadministration assessments of the outpatient are basically the same as those for the hospitalized patient. The nurse obtains a complete medical history and a history of the symptoms of the depression from the patient, a family member, or the patient's hospital records. During the initial interview, the nurse observes the patient for symptoms of depression and the potential for suicide. The initial physical assessment also should include the patient's vital signs and weight.

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