Exam 2 Notes
Ch. 17 Suicide
Nursing Assessment-High Risk Patients
o Behavioral clues:
- Giving away prize possessions
- Writing/leaving suicidal notes
- Want to watch for patients that have been depressed and have a sudden
burst of energy because the medications may give them the ability to
follow through with suicidal actions
o Support system
- If a patient has no satisfactory relationships, they are at risk
o Analysis of suicidal crisis
- Precipitating stressor (going through stress but also has a mental health
disorder)
- Relevant history (a lot of failures or rejection, lost job a couple of times)
- Life-stage issues (low ability to tolerate loss and disappointment)
o Psychiatric/medical/family history
- Previous psychiatric treatment for depression, alcoholism, presence of
debilitating illness, history of suicide in family
o Coping Strategies
- How have they handled previous crisis?
o Presenting Symptoms
- Ideation: has suicide ideas that are current and active
- Substance abuse: has current/excessive use of alcohol or other drugs
- Purposelessness: expresses thoughts that there is no reason to continue
living
- Anger: expresses uncontrolled anger or feelings of rage
- Trapped: expresses the belief that there is no way out of current situation
- Hopelessness: expresses lack of hope and perceives little chance of
positive change
- Withdrawal: expresses desire to withdraw from others or has begun
withdrawing
- Anxiety: expresses anxiety, agitation, and/or changes in sleeping pattern
- Recklessness: engages in risky activities with little thought of
consequences
- Mood: dramatic mood shift
- Acronym to remember IS PATH WARM*
o CASE
- Normalizing communicates they are not the only one who experiences
suicide ideation. Ex: Sometimes when people are in a lot of emotional
pain, they have thoughts of killing themselves. Have you had any thoughts
like that?
- Asking about behavioral events rather than opinions. Ex: What did you do
when you had those thoughts?
, - Gentle assumptions. Ex: What other times have you tried to attempt
suicide?
- Denial of the specific is helpful when a client generally denies ideation.
Ex: After the client denies suicidal ideation in response to a general
question, the nurse asks more specifically, “Have you ever thoughts of
overdosing?” “Have you ever had thoughts about shooting yourself?”
- Chronologically exploring the presenting suicide event, recent suicide
events, past suicide events, and finally the immediate suicide events can
broaden our understanding of the patient’s immediate suicidal intent in the
context of their behavior over time.
Planning and Implementation:
o Ask client directly “have you thought about harming yourself in any way?”
o Remove all harmful objects. Room searches as necessary
o Maintain close observation, one to one, every 15-minute checks. Close to nurses’
station
o Special care when giving meds (check mouth)
o Make rounds at frequent, irregular intervals
o One to one observation (constant supervision around the clock, always having
the client in sight and close. Documentation should indicate which staff member
is accountable for the client, with specific start and stop times. There is an
increased risk for suicide during staff rotation time)
Information for family and friends
o Take any hint of suicide seriously
o Do not keep secrets
o Be a good listener
o Emphasize ways the person’s suicide would be devastating to you and to others
Nursing Care:
o Primary Interventions: focus on suicide prevention through the use of community
education and screenings to identify individuals at risk
o Secondary Interventions: focus on suicide prevention for an individual client who
is having an acute suicidal crisis. Suicide precautions are included in this level of
intervention.
o Tertiary Interventions: focus on providing support and assistance to survivors of a
client who completed suicide
Ch. 22 Neurocognitive Disorders:
Confabulation in 4th stage of AD
Interventions for patients with dementia:
Risk for trauma (vulnerable to accidental tissue injury)
- Arrange the furniture
- Keep the bed in lowest position
- Room nearest to nurses station
- If person is a smoker keep the cigarettes
, - Help with ambulation (walker, cane, wheel-chair)
- Teach patient to hold on to railing, etc
- Call for assistance
- Put call button close
Agitated client
- Maintain low stimulation
- Remain calm and undemanding
- Avoid pressing person to perform activities that he/she is refusing
- Dancing, other rhythmic movements helps to redirect the patient
Wandering client
- Keep person on a structured schedule of recreational activities and a strict
feeding and toileting schedule
- Provide safety, enclose place for pacing and wandering
- Walk alongside for a while and gently redirect them back
- Ensure outdoor are electronically monitored
Disoriented client
- Try to keep client as oriented with reality as possible
- Use clock calendars, big clocks
- Allow patients to have many of their own possessions
- Place large colorful signs on the doors (dining room, bathroom, activity)
- Ensure the noise level is down
- Allow patient to go through old pictures
- Maintain consistency of staff
- Monitor medication side effects
Delusions and Hallucinations
- Minimize the focus on delusional thinking: do not disagree with made up
stories, gently correct patient, safe guide topic about real life events and
people
- Never argue
- Don’t ignore hallucinations-listen
- Assess side effects of meds
- Check hearing aid is working
- Check eyeglasses-own
- Other contributing factors-mirror, photo on wall (what is causing)
- Distract patient
- Assess if hallucinations are upsetting the patient
Impaired verbal communication
- Use calm and reassuring approach when interacting
- Use simple words, speak slowly, distinctly
- Always identify yourself and call patient’s name
Ch. 17 Suicide
Nursing Assessment-High Risk Patients
o Behavioral clues:
- Giving away prize possessions
- Writing/leaving suicidal notes
- Want to watch for patients that have been depressed and have a sudden
burst of energy because the medications may give them the ability to
follow through with suicidal actions
o Support system
- If a patient has no satisfactory relationships, they are at risk
o Analysis of suicidal crisis
- Precipitating stressor (going through stress but also has a mental health
disorder)
- Relevant history (a lot of failures or rejection, lost job a couple of times)
- Life-stage issues (low ability to tolerate loss and disappointment)
o Psychiatric/medical/family history
- Previous psychiatric treatment for depression, alcoholism, presence of
debilitating illness, history of suicide in family
o Coping Strategies
- How have they handled previous crisis?
o Presenting Symptoms
- Ideation: has suicide ideas that are current and active
- Substance abuse: has current/excessive use of alcohol or other drugs
- Purposelessness: expresses thoughts that there is no reason to continue
living
- Anger: expresses uncontrolled anger or feelings of rage
- Trapped: expresses the belief that there is no way out of current situation
- Hopelessness: expresses lack of hope and perceives little chance of
positive change
- Withdrawal: expresses desire to withdraw from others or has begun
withdrawing
- Anxiety: expresses anxiety, agitation, and/or changes in sleeping pattern
- Recklessness: engages in risky activities with little thought of
consequences
- Mood: dramatic mood shift
- Acronym to remember IS PATH WARM*
o CASE
- Normalizing communicates they are not the only one who experiences
suicide ideation. Ex: Sometimes when people are in a lot of emotional
pain, they have thoughts of killing themselves. Have you had any thoughts
like that?
- Asking about behavioral events rather than opinions. Ex: What did you do
when you had those thoughts?
, - Gentle assumptions. Ex: What other times have you tried to attempt
suicide?
- Denial of the specific is helpful when a client generally denies ideation.
Ex: After the client denies suicidal ideation in response to a general
question, the nurse asks more specifically, “Have you ever thoughts of
overdosing?” “Have you ever had thoughts about shooting yourself?”
- Chronologically exploring the presenting suicide event, recent suicide
events, past suicide events, and finally the immediate suicide events can
broaden our understanding of the patient’s immediate suicidal intent in the
context of their behavior over time.
Planning and Implementation:
o Ask client directly “have you thought about harming yourself in any way?”
o Remove all harmful objects. Room searches as necessary
o Maintain close observation, one to one, every 15-minute checks. Close to nurses’
station
o Special care when giving meds (check mouth)
o Make rounds at frequent, irregular intervals
o One to one observation (constant supervision around the clock, always having
the client in sight and close. Documentation should indicate which staff member
is accountable for the client, with specific start and stop times. There is an
increased risk for suicide during staff rotation time)
Information for family and friends
o Take any hint of suicide seriously
o Do not keep secrets
o Be a good listener
o Emphasize ways the person’s suicide would be devastating to you and to others
Nursing Care:
o Primary Interventions: focus on suicide prevention through the use of community
education and screenings to identify individuals at risk
o Secondary Interventions: focus on suicide prevention for an individual client who
is having an acute suicidal crisis. Suicide precautions are included in this level of
intervention.
o Tertiary Interventions: focus on providing support and assistance to survivors of a
client who completed suicide
Ch. 22 Neurocognitive Disorders:
Confabulation in 4th stage of AD
Interventions for patients with dementia:
Risk for trauma (vulnerable to accidental tissue injury)
- Arrange the furniture
- Keep the bed in lowest position
- Room nearest to nurses station
- If person is a smoker keep the cigarettes
, - Help with ambulation (walker, cane, wheel-chair)
- Teach patient to hold on to railing, etc
- Call for assistance
- Put call button close
Agitated client
- Maintain low stimulation
- Remain calm and undemanding
- Avoid pressing person to perform activities that he/she is refusing
- Dancing, other rhythmic movements helps to redirect the patient
Wandering client
- Keep person on a structured schedule of recreational activities and a strict
feeding and toileting schedule
- Provide safety, enclose place for pacing and wandering
- Walk alongside for a while and gently redirect them back
- Ensure outdoor are electronically monitored
Disoriented client
- Try to keep client as oriented with reality as possible
- Use clock calendars, big clocks
- Allow patients to have many of their own possessions
- Place large colorful signs on the doors (dining room, bathroom, activity)
- Ensure the noise level is down
- Allow patient to go through old pictures
- Maintain consistency of staff
- Monitor medication side effects
Delusions and Hallucinations
- Minimize the focus on delusional thinking: do not disagree with made up
stories, gently correct patient, safe guide topic about real life events and
people
- Never argue
- Don’t ignore hallucinations-listen
- Assess side effects of meds
- Check hearing aid is working
- Check eyeglasses-own
- Other contributing factors-mirror, photo on wall (what is causing)
- Distract patient
- Assess if hallucinations are upsetting the patient
Impaired verbal communication
- Use calm and reassuring approach when interacting
- Use simple words, speak slowly, distinctly
- Always identify yourself and call patient’s name
