Mood Change (depression, anxiety)

Also Consider:  Behavioral Disturbance, Delirium, Mental Status Change, Suicide potential 

1. Take Vital Signs

• Temperature:

• Blood Pressure:

• Heart Rate: 

• Respiratory Rate:

• Oxygen Saturation:

2. Evaluate Symptoms and Signs

• Not eating or drinking

• Negative Expressions:  Tearful, crying, irritable, scared, frowning

• Positive Expressions: Laughing, smiling

• Behaviors

• Interactions with others

• Statements made

• Fingerstick glucose (patients with diabetes)

• Unrelieved pain

• Alcohol intoxication or drug use, overdose

• Danger to self (injury, suicidal ideation) or others

• Events leading up to the mood change

3. Take Action using SBAR Report:

• Presence of other, significant symptoms or signs of illness 

  • Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.

• Immediately notify the medical staff & resident representative

  • Symptoms posing imminent danger to himself/herself or others, such as acute suicidal ideation.

• Notify medical staff on the next business day 

  • Recent onset of significant mood change impacting ADLs or functioning

• Notify medical staff at the next regular rounds 

  • Gradual mood change

4. Implement Management Plan

• Increase monitoring/supervision (15 minute checks, 1:1 observation, etc), inviting assistance from patient’s family and friends

• Assess risk for unsafe wandering and falls

• Remove items that may be used as weapons or otherwise cause harm to the patient or others

• Place on 24-hour report for 2-3 days

• Document symptoms and response to interventions each shift

• Update care plan regarding  fall risk, supervision for safety

• Review status and plan of care with designated representative

• Update advance directives, if appropriate.

2025-04-27