Suicide and Non-suicidal Self-Injury (NSSI) UNFOLDING Reasoning J. Thompson.

Suicide and Non-suicidal Self-Injury (NSSI) UNFOLDING Reasoning J. Thompson, 18 years old Primary Concept Coping – Maladaptive Interrelated Concepts (In order of emphasis) • Stress • Anxiety • Mood and Affect • Cultural competence • Clinical Judgment NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23% • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity • Basic Care and Comfort 6-12% • Pharmacological and Parenteral Therapies 12-18% • Reduction of Risk Potential 9-15% • Physiological Adaptation 11-17% Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved UNFOLDING Reasoning Part I: Recognizing RELEVANT Clinical Data History of Present Problem: J. Thompson is an 18-year-old African-American transgender male with a history of major depressive disorder (MDD) and suicidal ideation and self-harm behaviors. He arrives to the emergency department (ED) per emergency medical services (EMS) for evaluation of suicidal ideation and a recent attempt to harm himself. He became upset this morning following an argument with his roommate at his group home and cut self repeatedly on his left inner thigh using a metal tack. The patient thinks about how it would be easier to just go to sleep and never wake up. He denies any recent drug or alcohol use. He denies any thoughts of harm to others (homicidal ideation) Personal/Social History: The patient’s legal name is Jenny Thompson but prefers to use the name Jordon. Assigned female at birth, Jordon has identified as a transgender male since age 14. Jordan’s mother died of a drug overdose when he was an infant has no family that are involved in his life. He is a ward of the state and his county social worker is his closest support person. He plans to initiate gender-affirming surgery in the near future. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: Patient Care Begins: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: Current VS: P-Q-R-S-T Pain Assessment: T: 98.5 F/36.9 C (oral) Provoking/Palliative: P: 88 (regular) Quality: Denies R: 16 (regular) Region/Radiation: BP: 128/82 Severity: O2 sat: 99% room air Timing:Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: Current Assessment: GENERAL APPEARANCE: Calm, body relaxed, no grimacing, appears to be resting comfortably, admits to sleeping 7-8 hours each night. RESP: Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks, brisk capillary refill NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all four quadrants, states that his appetite is good and has been eating three meals a day. GU: Voiding without difficulty, urine clear/yellow INTEGUMENTARY: Several superficial partial thickness 8-10 cm lacerations of left inner thigh which patient confirms were recently made, minimal dried blood. Both inner thighs and upper arms reveal scarring (thin lines) which patient reports is from previous cutting episodes, skin turgor elastic, no tenting present FACULTY NOTE: Given patient history, it is important to complete a full body skin assessment looking for evidence of other self-harm behavior (cutting, burning, etc.) Mental Status Examination: APPEARANCE: Casually dressed in loose fitting, gender neutral clothes. Grooming adequate. Cooperative on admission MOTOR BEHAVIOR: No abnormal motor activity SPEECH: Clear MOOD: Sad mood; expresses much frustration. Rates anxiety at a 6 out of 10 AFFECT: Flat affect THOUGHT PROCESS: Linear THOUGHT CONTENT: Describes self as preoccupied with starting gender affirming surgery; no evidence of delusions when assessed PERCEPTION: Denies hallucinations INSIGHT: Somewhat limited; describes episode of cutting as being impulsive JUDGMENT: Impaired related to destructive coping recently; other behavior as impulsive Impulse control: appears limited when acutely upset COGNITION: Orientated x 4; recent and remote memory intact when tested; fund of knowledge is adequate SUICIDAL/HOMICIDAL: (include NSSI - Non-suicidal selfharm behaviors) • Suicide: reports he “thinks about how it would be easier to just go to sleep and never wake up”; denies plan; one suicide attempt 1 year ago by taking an overdose of old pain pills. Found by roommate and taken to the ER for treatment. • Homicide (harm to others/property): denied • NSSI: Cut self repeatedly on inner thigh with metal tack; has history of previous sel