a cognitive model for assessing depression and providing nursing interventions in cardiac intensive...

A cognitive model for assessing depression and providing nursing interventions in cardiac intensive care

Leayn H. Johnson and Sharon L. Roberts

Leayn H. Johnson RN, PhD, CNS, Associate Professor

Sharon L. Roberts RN, PhD, FAAN, Professor

California State University, Long Beach Department of Nursing

Correspondence to LHJ: 16932 Edgewater Lane, Huntington Beach, CA92649, USA

(Requests for offprints to LHJ) Manuscript accepted 28 March 1996

Depression is an emotion experienced by each individual at some point in his or her lifetime. For some, the feelings are temporary, such as when one feels momentarily let down. For others, the feelings are deeper and may last for longer periods of time. Deeper and longer lasting depression may occur when individuals are confronted by certain unfavourable types of life situations such as a major physiological loss. For a once healthy individual, the depression associated with a physiological loss has penetrated through the individual's prior coping process and defences.

Depression is a particularly common problem in individuals with a medical illness (Cavanaugh 1983). Heart disease is often experienced as a major loss for patients. Reports of depression in patients with coronary artery disease have ranged from 18% to 60% (Clark 1990). A broad range of physical disorders are commonly associated with depression. Among the most prominent disorders is congestive heart failure (Buckwater & Babich 1990).

For depressed congestive heart failure (CHF) patients, a critical care nurse needs to assess the factors contributing to depression and recognise behaviours reflective of depression to be able to make appropriate nursing diagnoses and devise a plan to manage the patient's depression. To help critical care nurses

accomplish this goal, this article contains an examination of depression as it applies to CHF patients according to Beck's cognitive triad (Ulerman et al 1984).

D E F I N I T I O N OF DEPRESSION

Depression is defined as any decrease in normal performance, such as slowing of psychomotor activity or reduction of intellectual functioning (Silverstein 1987). Depression refers to a wide range of human, emotional, and clinical states. As a mood state, depression is ubiquitous and encompasses such feelings as sadness and discouragement. As a symptom, depression occurs in a wide variety of reactions to stress and medical and psychiatric conditions. As a clinical state, it refers to a number of conditions in which the common and essential feature is a disturbance in affective mood, accompanied by related cognitive, psychomotor, psycho- physiological, and interpersonal difficulties (Buckwalter & Babich 1990). Since depression is a part of normal human experience, it is normal for CHF patients to experience depression when they are confronted with life- threatening illnesses (Silverstein 1990).

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), depres- sive cognitions and behaviours include persistent and pervasive feelings of dejection, gloominess, cheerlessness, joylessness, and un- happiness. Individuals with depression dwell on their negative and unhappy thoughts. Such individuals view the future as negatively as they view the present, they doubt that things will ever improve, anticipate the worst, and while priding themselves as being realistic, are considered by others to be pessimistic. Self-esteem is low and particularly focused on feelings of inadequacy (Frances 1994).

CASE S T U D Y

Mr O., a 60-year-old man, was admitted into the critical care unit with the diagnosis of CHF secondary to acute myocardial infarction (MI). Mr O.'s medical history included a myocardial infarction 3years ago. At the recent admission Mr O. was experiencing ankle swelling, weight gain, fatigue and weakness. Shortly after his admission, the patient's physician told him the clinical evidence, electrocardiograph (ECG) changes, chest film appearance and elevated serum isoenzymes, documented the diagnosis of anterior and inferior MI with CHF. Mr O. was advised to remain in the critical care unit

Intensive and Critical Care Nursing (1996) 12, 138-146 © 1996 Pearson Professional Ltd

Assessing depression and prov id ing nursing interventions in cardiac intensive care 139

(CCU) so that his ECG, haemodynamic parameters, serum isoenzymes, evidence of pain and response to medication could be closely monitored. During his stay in the CCU, Mr O. made five cognitive errors: arbitrary inference; selective abstraction; overgeneralisation; magnification; and personalisation. Table 1 is a summary of'the six cognitive errors which people with depression tend to make, according to Beck (1967).

First, Mr O. heard his physician's description of'his ECG, serum isoenzymes, haemodynamic parameters and blood gases and immedi- ately focused on the negative outcome of what happened to his heart. He did not understand the relationship between myocardial injury or loss and various diagnostic and treatment procedures. He assumed the initial description of his myocardial loss meant he would be likely to die or be severely limited in activity during his retirement. He did not hear a discussion of treatments designed to enhance myocardial contractility and subsequent cardiac output. In this instance he made both arbitrary inference and selective abstraction. He arrived at the negative conclusion that he would be dependent or incapacitated based on his perception of the physician's initial diagnosis, not on how the intra-aortic balloon pump would improve cardiac output or decrease the need for medications. Mr O. focused on the diagnosis to the exclusion of the beneficial effects of certain supportive interventions.

On the second day of his stay in the C C U he developed shortness of breath requiring additional medication (f,rusemide), higher levels of supplemental oxygen and closer observation. His nurse auscultated his chest for adventitious breath sounds, obtained arterial blood gases and increased oxygen level to 5-6L/min . The additional observation drew attention to the

I. Arbitrary inference: refers to the process of drawing a specific conclusion in the absence of evidence to support the conclusion or when the evidence is contrary to the conclusion

2. Selective abstraction: consists of focusing on a detail taken out of context, ignoring other more salient features of the situation and conceptualising the whole experience on the basis of this fragment

3. Overgeneralisation: refers to the pattern of drawing a general rule or conclusion on the basis of one or more isolated incidents and applying the concept across the board to related and unrelated situations

4. Magnification and minimisation: are reflected in errors in valuating the significance or magnitude of an event that is so gross as to constitute a distortion

5. Personalisation: refers to the patient's proclivity to relate external events to himself when there is no basis for making such a connection

6. Absolustic, dichotomous thinking: is manifested in the tendency to place all experiences in one of two opposite categories; for example, flawless or defective, immaculate or filthy, saint or sinner. In describing himself, the patient selects the extreme negative categorisation.

shortness of,breath. He made the error ofover- generalisation by interpreting the shortness of breath event as evidence that his condition was deteriorating. Furthermore, he magnified the shortness of breath and treatment into some- thing more clinically significant than it was.

Last, he made the cognitive error ofperson- alisation when he overheard two nurses dis- cussing another patient whose CHF worsened resulting in pulmonary oedema. He erroneously thought they were talking about him and subsequently related an external negative event to himself. The negative view of self held by a CHF patient like Mr O. can be reinforced when a comparison is made to other patients with the same or a similar problem. A patient looks for signs of progress or reversal as indica- tors of his or her rate of' recovery, and may think he will experience any complications observed in other CHF patients. The comparison without validation from the nurse can further lower the patient's confidence. However, when the critical care nurse explains the difference in the other patient's condition and describes the health team's response, the patient will be able to correct the cognitive error of personalisation.

C O G N I T I V E M O D E L O F

D E P R E S S I O N A P P L I E D T O A N

A C U T E C O N G E S T I V E H E A R T

F A I L U R E P A T I E N T

The cognitive model of depression has been influenced by Beck. The cognitive model developed by Beck posits that depression results from distortions of reality such that the depressed individual perceives the self', the world, and the future negatively (Budewalter & Babich 1990). Distorted thinking is not a good basis on which to decide what are and what are not likely to be effective therapeutic tasks (Holdsworth & Moore 1991). Helm points out that Beck gives cognition a more central role in producing and maintaining depression (Helm 1984). With Beck's cognitive behaviourat perspective, af,fective responses are determined by the way a person constructs experiences and anticipates the future. In this model, depression is the affective result of negative appraisals involving perceptions of personal failure (Helm 1984, Beck ~967). At the centre o f Beck's cognitive model is a cognitive triad: negative view of self, negative view of experiences, and negative view of future. Besides delineating a cognitive triad, Beck has also identified six errors depressed individuals can make which lead to negative conclusions. CHF patients commonly make one or more of'these errors.

140 Intensive and Critical Care Nursing

Negative view of self

The negative view of self-cognitive pattern causes CHF patients to see themselves as defective, inadequate, diseased or deprived. They believe that because of their presumed defects they are undesirable and worthless. Such patients lack the attributes they consider essential to attain happiness and contentment.

Loss factors contributing to a negative view of self include physiological loss, financial loss and life-style loss. During the CHF episode necessitating hospitalisation, it is difficult to determine which loss factor contributes to feelings of depression after the first shock of an acute illness like CHF and further myocardial loss. A normal period of depression follows in which the individual gives loss of health or the ability to function as previously. During this time, the patient may feel sad and withdraw further from others until he or she can accept the condition or acknowledge the loss (Lynch & Stevens 1985). For a CHF patient like Mr O. depression may result from a biological change secondary to the physical illness itself, or may reflect a maladaptive response or inability to cope with the illness (Lynch & Stevens 1985).

Symptoms of impending myocardial loss contributing to the current illness may have been ignored. Failure to recognise the warning signs through selective arbitration, magnification, or overgeneralisation of one symptom may result in guilt. For example, a CHF patient like Mr O. may have attributed the dependent oedema, weight gain, chest discomfort, fatigue or activity tolerance to diet or age. The patient may have coped with the threat of illness and hospitalisation by delaying medical and/or nursing interventions. For an individual like Mr O., such coping occurs to gain control over the threat, which becomes the anticipation that certain self-related goals will not be met. Critical care nurses help CHF patients to identify positive aspects of the illness, and help to identify the source of physiological threat so it can be perceived and interpreted.

The potential loss of immediate and long- term financial independence can be a source of depression for CHF patients like Mr O. He was approaching the end of his professional career, and to achieve his goal o f financial independence in retirement he needed to work an additional 5 years. N o w the threat o f CHF and its incapacitating symptoms, together with the need for expensive medical and therapeutic interventions, have inter- rupted these plans. Therapeutic interventions may include thrombolytic therapy, percuta- neous transluminal coronary angioplasty, intra-aortic balloon pump, dynamic car-

diomyoplasty, ventricular assist device or coronary artery bypass graft surgery. Each intervention has its own risk of complications and may extend the length of hospitalisation. They may have an impact on his perceived need to work, thereby complicating achieve- ment of his financial goal.

The loss of a valued life style resulting from financial and physical limitations can be a source of depression. The term 'valued life style' refers not only to how individuals live but to the con- tribution they make to their social world. Further loss of myocardial muscle mass leading to CHF may force the individual to reduce par- ticipation in some valued activity like work, social or family event. A CHF patient like Mr O. may experience activity intolerance, fatigue or alteration in comfort, which may reduce par- ticipation in working, exercising, playing with grandchildren or travelling.

Negative view of experiences

Depressed CHF patients like Mr O. have a tendency to interpret their ongoing experiences in a negative way. He saw the world as making exorbitant demands on him and/or presenting insuperable obstacles to reaching his life goals. Such individuals interpret interaction with the environment as representing defeat. These negative interpretations are evident when one observes how the patient construes situations negatively when more plausible, alternative interpretations are available.

Factors that contribute to a CHF patient's negative view of experiences are stress and loss of control. Stress is a personal interpretation that occurs when people believe their well- being is endangered (Lazarus & Folkman 1984). In addition, stress may actively lower the body's resistance thereby making the individual more vulnerable to illness. IndMduals with a particular illness, such as heart disease, may be especially prone to experiencing depression (Salta & Magruder-Habikik 1985).

According to Wilson (1987) stressors can be extrapersonal, interpersonal and intrapersonal. Extrapersonal stressors include the CCU, monitors, invasive procedures, know-- ledge deficit, activity limitations, lights, noise, sleep deprivation, and sensory deprivation. Davis (1978) found the following environmental items to be stressful: frequent drawing of blood; not knowing or understanding the illness or its seriousness; having no control over what was being done; having an intra- venous line in the arm; not being able to smoke; and being unable to move freely in bed because of equipment.

Depressed CHF patients may make the cognitive errors of overgeneralisation and magnifi-

Assessing depression and providing nursing interventions in cardiac intensive care 141

cation of the above events in the critical care environment. Some patients view the intrusive procedures, supportive devices, and diagnostic procedures as an invasion of privacy over which little control can be exerted. They may view the experience as confirmation of the severity of their illness and of the possibility of further problems.

A patient's immediate hospital experience and the manner in which care is organised can contribute to depression. Taylor (1979) pointed out that the structure of hospital care automatically contributes to feelings of loss of control and helplessness. Some patients react by becoming depressed, whereas others react with anger. Labelling a patient 'good' or 'bad' causes him/her to feel depersonalised and less likely to become involved in treatment procedures or other aspects of care (Taylor 1979). The patients may use environmental distortion in order to cope with the technological atmo- sphere of the CCU. A patient may erroneously view the cardioscope or haemodynamic monitoring equipment as controlling the heart. As a rhythmic pattern moves across the oscilloscope, the patient watches the nurse observe and record the rhythm or obtain haemodynamic pressures. Although aware that the mysterious looking pattern is his or her own heartbeat or cardiac pressures, the patient falsely believes that should the cardioscope be accidentally dis- connected, the heart would stop. Such a distorted, incomplete, and misleading view of the cardioscope is another example of the cognitive errors o f arbitrary inference, selective abstraction, and overgeneralisation.

Ira depressed patient like Mr O. makes cognitive distortions of the technical world, he or she may also make distortions about the people providing care. Wilson (1978) categorised interpersonal stressors to include visiting regu- lations, conversation of staff" nurses, excessive nurse-patient interaction, lack of explanations, and ineffective nurse/patient interactions.

A partial list o f psychological intrapersonal stressors identified by Wilson (1987) includes anxiety, depression, fear, denial, and psychiatric illness; some of the physiological interpersonal stressors include dysrhythmias, blood abnor- malities, increased units of blood transfusions, pneumonia, and local or generalised infection, developmental stressors include age or sex.

Loss of control can contribute to a patient's negative view of self. The acute illness is a life event over which the individual has little control. This lack of control over his or her physiological being is viewed as a significant factor in the individual's feeling of vulnerability to illness (Salta & Magruder-Habikil 1985). Stern and co-workers (1976) found that the perception of having control played a critical role in separat-

ing patients who were depressed from those who denied their illness. The depressed individuals perceived themselves as having a lack of control over the symptoms of their illness.

In addition to loss of control over the illness event and symptoms, a CHF patient may lose control over the decision-making process. Often members of the critical care team decide when the patient is to eat, be bathed, have visi- tors, and receive various procedures and treatments. The loss of initial decision-making control may depend upon the severity of the CHF. The nurse can help the patient to understand that the loss of decision-making control is temporary. After the initial physiological crisis has subsided, as the patient moves toward interde- pendence he or she, with guidance, can partici- pate in simple decisions that have a positive predictable outcome, and decide when to be bathed, to sit in a chair, or to ambulate in the room. When the patient has a sense of mastery over even the simplest of decisions, he or she begins to achieve a feeling of control.

N e g a t i v e v i e w of f u t u r e

As depressed CHF patients make long-range projections, they anticipate that their current difficulties or suffering will continue indefi- nitely. When a patient considers undertaking a specific task in the immediate future, he/she expects to fail (Beck et al 1979). Likewise, as a depressed CHF patient like Mr O. looks ahead he may anticipate that current difficulties will continue into the future. This negative view of the future involved forced dependency.

The fatigue, weakness or activity intolerance that limits physical activity may cause forced dependency. The CHF patient is dependent upon the critical care nurse. In addition, the patient may be dependent upon diagnostic or treatment procedure and supportive devices that not only monitor but limit every movement. A CHF patient like Mr O., when told by the critical care nurse and physician that he will remain in bed for a few days, may make the cognitive error of elective abstraction by focusing on the phrase 'remain in bed' to the exclusion of the important phrase 'few days'. Mr O. may not see the forced dependency role as being temporary.

Some CHF patients, because of their symptoms including the risk of complications, believe they will never be the same again. In this respect, the patient sees the future from a fixed position. Part of Mr O's involvement in life and future depended on a work ethic. His current need to work was financially linked to his family's future retirement planning. The CHF episode threat- ens the future and may force certain changes in life-style. Such changes may cause the patient to question the significance of a future role.


A S S E S S M E N T O F D E P R E S S I O N I N A C H F P A T I E N T

In order to confirm the nursing diagnosis of depression, the critical care nurse assesses the defining characteristics associated with depression. Table 2 is a summary of defining characteristics (Field 1985, Roberts 1987).

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) requires five of the following seven characteristics for the patient to be considered depressed:

• Depressed mood most of the day, nearly ever day (feels sad or empty)

• Diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

• Weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day

• Insomnia or hypersomnia nearly every day • Psychomotor agitation or retardation nearly

every day • Fatigue or loss of energy nearly every day • Feelings of worthlessness or excessive or

inappropriate guilt nearly every day • Diminished ability to think or concentrate,

or indecisiveness, nearly every day • Recurrent thoughts of death or recurrent

suicidal ideation without a specific plan (Frances 1994).

Once the defining characteristics have been identified and their origin explored, the critical care nurse can intervene.

Agitation Indifference Anger Indigestion Anorexia Insomnia Anxiety Irritability Avoidance Lack of interest Boredom Loss of feeling Careless appearance Low self-esteem Chest tightness Muscle aches Confusion Nausea Constipation Poor communication skills Crying Sadness Denial Self-criticism Dependence Sleep disturbance Diarrhoea Slow thinking Diurnal variations Social withdrawal Emptiness Submissiveness Fatigue Tachycardia Fearfulness Tension Feeling of worthlessness Tiredness Guilt Ulcers Headaches Weight loss/gain Hopelessness Indecisiveness

N U R S I N G I N T E R V E N T I O N S A S S O C I A T E D W I T H D E P R E S S I O N

The behaviour of a depressed CHF patient may be determined by the way he or she perceives the environment and interprets events within the environment (Grinspoon 1988). The nursing interventions related to such patients are organised around cognitive behavioural therapy. The nurse's aim, through cognitive therapy, is to alter mood by changing the patient's thinking. In the cognitive theory approach, depression is a result of distorted thinking (Clark 1990). The CHF patient, like Mr O., may remain depressed because he is inclined to see himself as worthless, the world as hostile, the future as hopeless, and every accidental misfortune as a judgment on himself (Grinspoon 1988). The critical care nurse attempts to change the patient's negative cognitive triad by encouraging a positive view of self, a positive view of experiences and a positive view of the future. Table 3 is a summary of nursing interventions.

P o s i t i v e v i e w of sel f

Critical care nurses help depressed CHF patients to achieve a positive view of self by reducing procedural distress, restoring control over the illness, facilitating health promotion, establishing interpersonal relationships, establishing an activity schedule and facilitating positive thoughts.

Reduce procedural distress Diagnostic and treatment procedures experienced by a CHF patient during life-threatening illness are major sources of distress contributing to feelings of depression. Procedural distress is defined as an unpleasant physical sensation and negative psychological stress associated with specific diagnostic or treatment procedures (Porter 1995). Physically invasive procedures involve objects such as needles, tubes and catheters. Mr O. experienced the procedural distress of suc- tioning, pulmonary artery catheterisation for haemodynamic monitoring, mechanical ventila- tion and intra-aortic balloon pump. A critical care nurse provides information about aspects of a procedure that can be observed or experienced by someone other than the patient. The objective or procedural information includes prepara- tion about the timing of the procedure and the environment or conditions, in which it is per- formed (Porter 1995). Procedural information allows CHF patients like Mr O. to match ongoing events to their expectations in an attempt to avoid making cognitive errors. When a CHF patient interprets procedures as non-threatening and understands why procedures are being per-


Cognitive model to avoid depression Positive nursing interventions

Positive view of self

Positive view of experiences

Positive view of future

Reduce procedural distress Restore control over the illness Facilitate health promotion Establish interpersonal relationships/

communication Establish an activity schedule Facilitate positive thoughts

Personalise the environment Reduce physical stressors Facilitate decisional control

Establish realistic goals Clarify values Facilitate acceptance of the future

formed, distress will be reduced and a sense of positive view of self is enhanced.

Restore control over illness Critical care nurses restore control over the heart failure illness experience through the pro- vision of concrete objective information (COl). COI consists of sensory information (Porter 1995). Sensory information is the sub- jective experiences associated with the procedure, what the CHF patient will see, hear, smell, feel and taste. Providing sensory information enhances or stimulates cognitive pro- cesses that will reduce the emotional response experienced by a CHF patient encountering threatening stimuli, such as invasive diagnostic or treatment procedures. The nursing intervention will also improve coping responses to the perceived stressful event (Sime 1992). Specifi- cally, the nurse's goal involves linking sensory experiences such as pain or pressure to their cause and ensuring that temporal qualities like frequency, duration and change over time are linked to appropriate sensations and elements of the event (Christman et al 1992).

Facilitate health promot ion Critical care nurses facilitate health promotion through use of cognitive reappraisal. Cognitive reappraisal is a process in which stressful stimuli are evaluated for their impact and meaning. A critical care nurse emphasises the positive aspects of a situation when a CHF patient like Mr O. becomes focused solely on his fears for the worst, so that he can reappraise his thoughts. Helping the individual to reappraise a situation like the illness, diagnostic procedures or treatment interventions adjusts distorted pat- terns of thought and reduces cognitive errors by shifting perspective. A person like Mr O. can then regain control o f the fearful situation.

The nurse uses cognitive reappraisal to provide information. Information processing is

directed toward modifying a negative or distorted interpretation o f the current illness, treatment and/or illness. As medication and treatments strengthen myocardial performance, the need for haemodynamic monitoring and counterpulsation may decrease. A CHF patient like Mr O. is then in a position to reappraise his condition and avoid feelings of depression. The nurse and patient agree upon the importance of complying with health promotion behaviours such as medication, diet, activity, and keeping appointments after discharge. These health promotion behaviours can create a positive view of self.

Establish interpersonal relationships Critical care nurses keep in mind that a trusting relationship provides the foundation from which a sense o f nurse-patient closeness can be achieved. Because of the various intrusive diagnostic and treatment procedures, the nurse becomes physically close to the CHF patient. The critical care nurse's respect for the patient's sense of dignity at this time facilitates interpersonal closeness (Roberts 1981). Active listening is used to establish a communication bond. Active listening is the skill of understanding what another is saying and feeling, and com- municating to that person what you think he is saying and feeling. Mr O's nurse actively lis- tened to his concerns, fears and misperceptions. The nurse learned about Mr O., including his family and work, so that his care could be indi- vidualised. A CHF patient is better able to understand self and to experience being under- stood by another caring person through that person practising active listening.

Establish activity schedule Another way the nurses lessen self-criticism and help a depressed CHF patient to achieve a more realistic view is to establish a task or activ- ivy schedule. The patient is encouraged to accomplish specific tasks, such as bathing or shaving, that he or she enjoyed before hospitalisation. Next, the nurse structures specific activities that can be successfully accomplished. According to Gilbert (1984), once mastery of activities or task successes are identified they can be arranged hierarchically according to the degree o f difficulty from the patient's perspective (Gilbert 1984). For example, an MI patient experiencing activity intolerance can feel a sense of success through gradual increments in activity: sitting up in bed; sitting at the edge of the bed; standing; walking to a chair; and even- tually walking around the bed. With each phase o f the activity schedule, the patient is encouraged to evaluate his or her accomplishment. For example, should the patient experience


shortness of breath while walking to a chair the symptom can be expressed and clarified, rather than overmagnified in such a way that the patient is afraid to extend the activity schedule. The nurse clarifies the cognitive error and paces the patient's activity schedule according to his or her ability. With each activity success the patient is motivated to accomplish more difficult tasks or activities, thereby fostering a positive view of self.

Facilitates posit ive thoughts Nurses attempt to increase each patient's self- concept or self-esteem by facilitating positive thoughts regarding the set£ A depressed patient who had a low self-esteem before the physiological crisis will, in all probability, have the low self-esteem reinforced. Raising the patient's self-esteem or self-concept involves identifying positive gains in physiological status. When the nurse identifies physiological gains, such as the absence ofdysrhythmias, normal serum isoenzymes and normal arterial blood gases, the depressed patient is able to see progress. Progress can only be found when the knowledgeable provider o f patient care identifies positive changes. Nurses help the patient to focus on small accomplishments rather than on the entire illness event, since focusing totally on the latter will only result in being overwhelmed or discouraged. A positive view of self can also be facilitated by encouraging the patient to focus on accomplishment.

Positive v iew of exper ience

A positive view of experiences by a CHF patient is accomplished through personalising the environment, reducing physical stress and facilitating decisional control.

Personalise the env ironment When CHF patients see the critical care environment with all its technology as a facilitator of health, they can develop a positive attitude toward experiences associated with treatment of the illness. Personalising the critical care environment is accomplished through environmental structuring, which facilitates a positive view of experiences by making the space in which the patient must temporarily reside less sterile. The space may be too small to contain many personal possessions, but it can contain drawings, pictures, cards, glasses, a clock, or familiar reading material. Such possessions may have special significance to the patient. Drawings from children or grandchildren can have a positive influence on alleviating depressed feelings. The nurses' environmental goal is to create space for valued personal possessions.

Reduce physical stressors Critical care nurses can reduce physical stressors through use of externally oriented techniques, such as progressive relaxation, and internally oriented procedures, such as guided imagery. Progressive relaxation is an intervention used to reduce high levels of stress by providing a CHF patient like Mr O. with a technique for exert- ing control over the body's response to tension and anxiety. Stress can cause an increase in heart rate, which has a negative effect upon a CHF patient's coronary artery perfusion through shorter diastole. Tachycardia reduces myocardial oxygen supply while increasing myocardial oxygen demand. Progressive relaxation can reduce heart rate, respiratory rate and myocardial oxygen demand. The nurse teaches CHt? patients a progressive muscle relaxation technique of tensing and relaxing a gross muscle group while attending to the difference in sensation of tension so as to reduce it. Such patients as Mr O. can then use the relaxation technique when confronted with a stressful intervention, and after discharge when a reduction in work-related stress is needed.

Guided imagery is the formation of a mental image of an object that is usually only perceived through the senses. Images can have visual, auditory, olfactory, gustatory and/or tactile- proprioreceptor qualities (Sodergen 1992). CHF patients like Mr O. are taught guided imagery strategies to assist them to think about another more pleasant image than the stressful or painful one in critical care. The critical care nurse teaches the CHF patient to imagine being in a place that he/she finds relaxing. It might be recalling a favourite view, trip or activity. The nurse then suggests that the patient allow the image that represents the illness to form so that he or she can practice changing the image to the more positive one. For example when the nurse was assessing haemodynamic parameters, using tracheal suc- tion or positioning Mr O., guided imagery was useful for the patient to control his illness experience.

Facilitate decisional control Critical care nurses can enhance a positive view of the experience by helping CHF patients to gain a sense of control by making decisions. Decisional control is the choosing or contributing to choice of alternative courses of actions. The individual may choose from among a number of options that are available (Sime 1992). Acknowledging a range of choices and making decisions reduces CHF patients' sense of depression in given situations. The decisional options selected by the critical care nurse need to be personally meaningful to the particular CHF patient. For example, Mr O. may


want to decide where to place get-well cards, when to change position, when to exercise his legs after cessation of counterpulsation, when to ambulate or which diversional activities to begin. In each instance, the critical care nurse helps him to make the decision by providing realistic alternatives. Decisional control is an effective strategy to lessen depression if."

• Decisional control options are realistic and available to the individual

• Decisional control options are limited in number and presented as an opportunity

• Decisional control options are described clearly and explicitly

• Decisional control options are personally relevant to the patient (Sime 1992).

Before an opportunity for decisional control is presented, the nurse must formulate thought- ful explanations for the effects o f choices to be made by CHF patients like Mr O.

Posit ive v i e w of f u t u r e

Critical care nurses facilitate a positive view of the future by helping CHF patients to establish realistic goals, clarify values and facilitate acceptance of the future.

Establish realistic goals Critical care nurses provide time-based goals through use o f mutual goal-setting. Mutual goal-setting is a process whereby a nurse and patient collaboratively define a set o f patient goals and agree on the goals to be attained (Maves 1992). Goal-setting gives direction for the delivery o f care and the rationale for specific nursing actions. Patient goals can range from being simple to more complex. For example, in the case o f Mr O., his activity to meet physical needs could begin by sitting in the bed, then progressing to stand, walk to a chair or commode, walk around the bed, and finally walk in the hallway. Before goal- directed activity begins, the nurse warns the patient he may initially experience some fatigue, shortness o f breath, weakness or tachycardia. As the planned activity begins, the nurse asks the patient to evaluate his status, and together they determine how many phases o f the activity goal will be achieved each time.

Sometimes CHF patients need to adjust the image they have o f themselves. Failure to make adjustments may lead a patient to have unrealis- tic expectations or goals. Based upon predis- charge diagnostic findings and consultation with the patient's physician, each patient is given concrete information regarding such areas as the amount of physical activity safely allowed, the type and examples of dietary

restrictions, and medications, including potential side-effects, and how and when the medication is to be taken.

Clarify values Critical care nurses create an environment that provides opportunities for reviewing values. A function of values is to serve as the foundation for decisions and choices. Each nurse uses value clarification to assist patients in learning the process of valuing so as to be clearer about their own values (Wilderding 1992). An assessment o f the values of a CHF patient like Mr O. will help him see the dissonance between his values and behaviours. If the patient values health, he is encouraged to change certain behaviour, and will value health promotion behaviours more than those contributing to further illness. Value clarification can also be effective in helping a patient with decisions regarding diagnostic and/or treatment procedures. Reviewing personal values can provide a CHF patient with a positive view of the future.

Facilitate acceptance o f the future Finally, nurses intervene by helping patients accept the future. CHF patients may use avoidance behaviour when thinking about the future. They may blame themselves for any perceived or real future changes in lifestyle that will also have an affect upon the family unit. Once the initial impact o f the illness has subsided, a nurse may help the patient con- front these feelings so that he or she can con- struct new ways of coping with the events and subsequent losses or changes in his or her world. If a patient continues avoidance behaviour, it may be necessary for the nurse to consult with a psychiatric clinical specialist, psychiatrist or physician. Regardless o f how the behaviour is approached, a depressed patient quickly learns that the nurse is con- cerned about his or her progress. In this respect, the critical care nurse is a positive reinforcer from w h o m the patient and the family can draw strength, compassion and understanding.

S U M M A R Y

In summary, CHF patients are at risk of experiencing depression. Depression, as a behaviour, can cover a wide range of alterations in affective state. While experiencing feelings of depression, CHF patients can react through negative appraisal o f self, experiences and future. Within this negative view of self triad, six cognitive errors can be made that serve to reinforce a negative perception. Regardless o f


t h e speci f ic c o m p o n e n t w i t h i n B e c k ' s c o g n i t i v e

t r iad, a cr i t ical care n u r s e d i a g n o s e s d e p r e s s i o n

a c c o r d i n g to d e f i n i n g charac te r i s t ics . O n c e a

n u r s i n g d i agnos i s is m a d e , n u r s i n g i n t e r v e n -

t i ons are e s t ab l i shed to p r o m o t e a pos i t i ve v i e w

o f self, a pos i t i ve v i e w o f e x p e r i e n c e s , a n d a

pos i t i ve v i e w o f t h e fu t u r e .

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a cognitive model for assessing depression and providing nursing interventions in cardiac intensive...

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