Psych Exam 3 - Ch. 25 (Suicide & Non-Suicidal Self Injury)

-"I can't take my life anymore. I can't handle this." Overt statements that indicate risk for suicide include remarks like "I can't take it anymore" and "Life isn't worth living anymore." Therefore, the nurse identifies "I can't take my life anymore" as an overt statement made by the patient that indicates suicide risk. "Things never work out for me," "Nothing feels good anymore," and "I'm sure everything will be fine eventually" are covert statements, not overt statements. p. 479

Ask if the patient has any plans to commit suicide. It is important for the nurse to directly ask patients if they have any plans to commit suicide. Research shows that asking about suicidal ideation does not induce ideas of suicide in a person, and in fact it is a professional responsibility of a nurse to do so. Talking about it can lead to problem-solving alternatives and decrease isolation in a patient. Asking the patient about plans to commit suicide is priority, and once this is confirmed, the health care provider and security staff may be informed. Ignoring the patient may put the patient at high risk of self-harm. p. 479

-"I can't keep relying on alcohol." -"I don't know where to go or who to talk to." Stating "I don't know where to go or who to talk to" or "I can't keep relying on alcohol" indicate self-reflection and an understanding that change may still be possible. The realization that help may be available and that alcohol isn't a good coping strategy shows hope. Saying "I won't be a burden on anyone anymore," "I just can't stand this pain any longer," and "I know how to make it all better" are statements lacking in hope. p. 480, Table 25.2

-Determining if the patient is using appropriate coping skills -Determining if the patient is communicating thoughts and feelings accurately Evaluation of non-suicidal patients engaging in self-harm includes determining whether the patient is communicating thoughts and feelings accurately and whether the patient's perception is that harmful behaviors are being replaced with appropriate coping skills. If the patient is replacing harmful behaviors, he or she will not be participating in the harmful behaviors. The purpose of the evaluation is not to determine whether the patient is enjoying life again or whether the patient is becoming more aware of prevention strategies. These may be more appropriate outcomes for different nursing diagnoses. p. 487

The patient is at higher risk of suicide. The nurse should appropriately evaluate the suicide plan of the patient. Patients with definite intention and time are at high risk. Based on the method of lethality, patients can be classified as higher risk and lower risk. Carbon monoxide poisoning, using a gun, jumping off a high place, or car crash indicate high risk. Depressive patients normally feel rejected and avoid social gatherings. The statement by the nurse does not indicate that the client is socially withdrawn. Although delusions are not a high risk of suicide, they can result in suicide. The patient does not have manifestations of delusions. The patient is depressed and sad but not aggressive, so there is no harm to others. p. 479

"I think things will be better soon." The response "I think things will be better soon" may be a covert, or indirect, clue that the patient is thinking of suicide. "I know a lot of people care about me and want me to get better," "I have suicidal thoughts at times, but I don't have any plan and don't think I would ever actually hurt myself," and "I don't have a good support system, but I am planning on joining a recovery group" are all statements that, while they may be discussed further, are not clues to suicide but rather clear communication. p. 479

Ask the patient open-ended questions about the incident. Risk of suicide in a family member of a person who has committed suicide is 4.5 times higher than in the general population. Therefore, it is important to ask open-ended questions about the incident and review the current situation of the patient. Mentioning or talking about the daughter can reduce hurt, stigma, and isolation in the patient. Survivors always want their loved ones to be remembered, so it would be inappropriate to ask the patient not to think about his or her child anymore. The nurse should always encourage the patient to express feelings about the traumatic event. This will make the patient feel comforted. p. 485

"I feel like sleeping forever and never waking up again." The statement that the patient feels like sleeping and never waking up again is a covert statement. The statement indicates that the patient is frustrated with the illness and wants to die to get rid of it. The statement that the patient does not want to take the medications as they are costly indicates that the patient is unable to afford the medication. The patient needs financial assistance. The patient is upset with people for their insensitive behavior; this indicates that the patient is depressed. That the patient's family wants the patient to be in a rehabilitation center indicates that the patient is highly motivated and wants to recover soon. p. 479

-Keep electrical cords to a minimal length. -Use plastic utensils for serving food to the patient. -Install breakaway shower rods and recessed shower nozzles. The history of the patient indicates a high risk of suicide. Therefore, the nurse should take all measures to minimize suicidal behavior in the patient. Some of the steps to be taken include using plastic utensils for serving food, keeping electrical cords to a minimal length, and installing breakaway shower rods and recessed shower nozzles. This patient should not be assigned a private room, and the door of the room should always be kept open. It is important for the nurse to go through the belongings of the patient in his presence and remove all potentially harmful objects. p. 487

"A few weeks ago, one of my son's classmates also attempted suicide in the same way." Copycat suicide is commonly seen during adolescence. Adolescents may glamorize the suicides of peers and classmates and perform copycat suicide due to immature reasoning and the function of an underdeveloped prefrontal cortex. The statement that the patient was worried about his poor performance on school exams indicates that academic performance was one of the probable reasons for attempting suicide. The statement that the patient's classmates are responsible for the suicide indicates that the patient's mother is blaming others, or that the patient has been the victim of bullying but it does not indicate risk for copycat suicide. The statement that the patient fought with his parents about school does not indicate a risk for copycat suicide. p. 477

Clozapine Antipsychotics may be prescribed to suicidal patients who experience psychotic or bipolar manic episodes. Since the patient's family expressed concern regarding side effects, the patient is most likely to be prescribed a second-generation antipsychotic, such as clozapine, with a lower risk of side effects than first-generation antipsychotics. Fluoxetine is an antidepressant, which would not be prescribed to this patient. Haloperidol is a first-generation antipsychotic with a greater risk for adverse side effects. Diazepam is an antianxiety medication, which would not be prescribed to this patient. p. 482

"Do you have any sort of suicidal ideas or plans?" It is important for the nurse to be aware of verbal and nonverbal hints of suicide by a patient to prevent suicide. When there is a sudden rise in the mood and energy of a depressed patient, the nurse should understand that the patient may have suicidal ideation. These behavioral changes may be the patient's attempt to mask suicidal intent. In such situations, the nurse should ask the patient directly about suicidal ideation. The patient should not be discharged as the patient is not safe. The patient should not be congratulated for recovery from depression because the patient is still not mentally stable. The patient does not seem to have recovered from depression. Therefore the nurse should not express satisfaction with the patient's recovery. p. 479

Reports of abusing alcohol since the age of 16 Indirect self-destructive behaviors are any activity harmful to the person's physical well-being that may result in death. Alcohol abuse is an example of such behavior. A suicide attempt is a direct self-destructive behavior. Regular episodes of hypoglycemia are examples of risk for physical harm but are not necessarily indicators of self-destructiveness unless there is some element of conscious attempt at self-harm. Suicidal thoughts without a plan are considered direct self-destructive behaviors. p. 480, Table 25.2

Have the patient identify three people to call if the patient is overwhelmed by hopelessness. For suicidal patients treated in the community, establishing a network of individuals to whom the patient may turn if the suicidal urge becomes great is important. p. 480, Table 25.2

-Homosexuality may be a trigger for these behaviors. -The injuries can be a self-inflected means of punishment. -Cutting and biting are common manifestations of this disorder. -The patient generally has more than one method to inflict injury. These behaviors most commonly consist of cutting/carving, burning, scraping/scratching skin, biting, hitting, skin picking, and interfering with wound healing. Half of self-injurers report multiple methods. These actions can be used to punish themselves, to connect with others, to get attention, to escape a responsibility, or to avoid a situation. Risk factors for nonsuicidal self-injury include depression in either parent, non-heterosexual orientation, and depression. Non-suicidal self-injury begins between 10 and 15 years of age, peaking in the late teens. Hospital admission data confirms a decline in the behavior between 25 to 29 years of age. p. 486

Asking the patient directly if he or she is thinking of attempting suicide. Covert references should be made overt. The nurse should directly address any suicidal hints given by the patient. Self-destructive ideas are a personal decision. Talking openly about suicide leads to a decrease in isolation and can increase problem-solving alternatives for living. People who attempt suicide, even those who regret the failure of their attempt, are often extremely receptive to talking about their suicide crisis. p. 479

A patient with schizophrenia is at great risk for attempting suicide. Individuals with schizophrenia are 50 times more likely to attempt suicide than the general public. More women attempt suicide, but more men are successful. Suicide is the tenth leading cause of death in the United States. Native Americans and Alaskan Natives have high suicide rates. p. 476

"Do you have access to a gun?" The evaluation of a suicide plan is important in determining the degree of suicidal risk. Three main elements that must be considered when evaluating lethality are whether there is a specific plan with details (in this scenario, a self-inflicted gunshot wound), how lethal is the proposed method (guns are high lethality methods of suicide), and whether there is access to the planned method (does the patient have a gun). People who have definite plans for the time, place, and means are at high risk. "Why" questions are probing, nontherapeutic communication techniques. "Have you failed any other subjects?" and "Did something happen with your parents?" are yes/no questions that do not encourage the patient's self-disclosure. p. 479

-Minimizing access to firearms -Publicizing community-based suicide prevention service facilities -Providing community educational focusing on the identification of warning signs -Identify strategies to minimize the stigma attached to seeking mental health services Goals for suicide prevention include developing and implementing strategies to reduce the stigma associated with substance abuse, being a consumer of mental health, and suicide-prevention services; promoting efforts to reduce access to lethal means and methods of self-harm (males use firearms quite frequently to commit suicide); implementing training for recognition of at-risk behaviors; and improving access to mental health and substance abuse services. Screening should include all males, but teens and males over 75 are at high risk. p. 482, Box 25.3

-Losing a job -The death of her parent The nurse should know about the risk factors of suicide. Unemployment and death of a loved one are two of the risk factors. However, pregnancy, access to health care, and a sense of responsibility for the family are protective factors for suicide. p. 477

Second-generation antipsychotic drug A second-generation antipsychotic drug is generally prescribed to patients with bipolar disorder and psychotic disorder due to few side effects. First-generation antipsychotic drugs are not generally prescribed to patients suffering from bipolar disorder as they have potent side effects, like tongue twitching, blurred vision, etc. Tricyclic antidepressants and monoamine oxidase inhibitors should not be prescribed as they have potent side effects, like hypertensive crisis. It can be fatal if a patient with suicidal intentions takes an overdose of these medications. p. 482

Situational low self-esteem Patients with situational low self-esteem have feelings of worthlessness and being a burden on family and others. Disabled family coping is characterized by ineffective communication with the family and unavailability of the family. Patients with impaired social interaction have few supportive groups and don't interact with others. Intense feeling of isolation, deprivation, and lack of love can be seen in patients with social isolation. p. 480, Table 25.2

After a highly publicized suicide of a public figure Theories of suicide have recently focused on a combination of suicidal fantasies with loss of job, rage, guilt, or identification with an individual who has committed suicide. A person commits copycat suicide after a highly publicized suicide of a public figure or an idol or a peer in the community. Losing a job, losing self-esteem due to various reasons, and feeling trapped in a jail may also be reasons for committing suicide, but they are not the reasons for a copycat suicide. p. 477

Scratching one's own face Parasuicide or nonsuicidal self-injury is the term used when a person directly and deliberately attempts to injure one's own body, which does not result in death. Examples of such actions include scratching skin, cutting, biting, burning, and skin pricking. Jumping off a tall building, shooting oneself with a gun, and taking sleeping pills are all lethal methods of suicide. These can cause immediate death of the patient. p. 486

Giving away possessions Giving away possessions, as well as writing letters and organizing financial affairs, is an example of nonverbal behaviors of a person who might be suicidal. Going to the doctor more frequently, finding excuses to not leave the house, and looking through sentimental belongings are not always associated with suicide. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. p. 470

-Pt. w/ anorexia -Pt. w/ depression -Pt. w/ PTSD Patients with depression, anorexia, and posttraumatic stress disorder are at a greater risk of suicide, as suicidal ideation is the result of inner pain, sadness, helplessness, and hopelessness. Attention deficit disorder and psychosis are not comorbidity factors that put patients at risk for suicide. p. 476

-88-year-old Caucasian male -26-year-old Alaskan Native male -17-year-old African American female Men, particularly white men of advanced age, have a higher risk than women for suicide. Among American Indians/Alaska Natives aged 15 to 34 years, suicide is the second-leading cause of death. Hispanic and Black, non-Hispanic female high-school students in grades 9 to 12 have higher percentages of suicide attempts than White, non-Hispanics. Among females, those in their 40s and 50s have the highest rate of suicide. pp. 476, 478, Box 25.1

-Count the kitchen utensils daily -Lock the utility rooms, kitchen, and office The nurse should lock the utility rooms, kitchen, and offices and instruct all the staff members to do so. The nurse should count the number of utensils daily to ensure that the patients don't take harmful objects from the kitchen. The ward must be kept free of harmful objects, like glass vases and nails. The nurse should close the windows to prevent the patients from escaping. The bathrooms must be made jump-proof and hanging-proof by installing breakaway showers. p. 484, Box 25.4

-Give adequate support to the staff of the unit. -Review the events to find the overlooked clues. -Recommend conducting psychological postmortem. The staff may experience post-traumatic stress disorder if a patient commits suicide at the hospital under their watch. A review of the events must be done to find the overlooked clues in the patient's behavior. This helps to avoid future mistakes and improve the quality of treatment. The nurse should support the staff to help them cope with the event. A thorough psychological postmortem should be done to determine any faulty judgment of the staff and to improve the treatment protocol. The staff should not be suspended. The patient's family must be informed immediately. p. 485

Serotonin Low serotonin levels have been noted among individuals who have committed suicide. While γ-aminobutyric acid, dopamine and acetylcholine are neurotransmitters they are not believed to be associated with suicidal ideations. p. 476

Clozapine Clozapine decreases the risk of suicide in patients with schizophrenia. However, these patients should be regularly monitored for severe side effects of clozapine, like agranulocytosis, myocarditis, and altered glucose metabolism. A common side effect of metformin is gastrointestinal disturbance; cetirizine can cause drowsiness; and paracetamol in large amounts can lead to liver toxicity. p. 482

Every 15-30 minutes When patients are at high risk of suicide and assessment shows that they may follow a plan of self-harm, the nurse should keep them under 24-hour surveillance. The nurse should chart the patient's whereabouts and record his or her mood, verbatim statements, and behavior every 15-30 minutes. The patients may cause self-harm if the interval between two checks is large, such as thrice a day, every 60-120 minutes, or every other day. p. 484, Table 25.3

One-on-one observation by the staff. One-on-one observation allows for constant supervision, which minimizes the patient's opportunities to cause self-harm. Although educating visitors about potentially dangerous gifts, restricting the patient from potentially dangerous areas of the unit, and removal of personal items that might prove harmful are appropriate, they do not have the impact that one-on-one observation has. p. 484, Table 25.3

This student has a higher suicide risk than his or her heterosexual peers. Suicide is the third leading cause of death among lesbian, gay, bisexual, and transgender (LGBT) youth in the United States. Informing the family may or may not change the risk. LGBT youth are more likely to attempt suicide than their heterosexual peers. p. 477

Ask the patient, "Do you have any thoughts of harming yourself?" The patient's comment suggests that hopelessness may be present. The nurse's first action is to assess suicidal thinking and intent. Suicide is more than 50 times higher among patients diagnosed with schizophrenia than that of the general population and is the leading cause of early death in this population. About 40% of patients diagnosed with schizophrenia attempt suicide at least once. Giving recognition for adherence to the treatment plan, reflecting, and exploring the patient's future goals are actions that may occur later. p. 479

"I'd like to hear about how you are feeling now and the image you have of yourself." The nurse should give frequent opportunities for discussion of feelings through verbal invitation and stated concern. These topics are pertinent to the care of the suicidal patient: suicide prevention, hope instillation, coping enhancement, self-esteem enhancement, family mobilization, and support system enhancement. "Why" questions are probing and nontherapeutic communication techniques. While giving recognition is a therapeutic communication technique, asking a yes or no question about the patient's readiness for discharge does not invite further dialogue. Giving advice is a nontherapeutic technique. p. 479

-Ineffective wound healing -Presence of scratches on the skin Parasuicide is also known as nonsuicidal self-injury. The patient tries to cause bodily harm by scratching the skin, biting, and interfering with wound healing. The presence of scratched skin and ineffective wound healing indicates that the patient had nonsuicidal self-injuring behavior. The presence of extreme happiness is a covert emotion and indicates that the patient has suicidal intention. Impaired nonverbal communication, the need for assistance while eating, and lack of hygiene are seen commonly in most psychiatric patients. They don't indicate parasuicidal behavior. p. 486

The patient is contemplating suicide. The factors that put this patient at higher risk of suicide include age, gender, lack of social support, lack of spouse, and a chronic medical condition. When such a patient makes a covert statement like "I won't be a problem much longer," the nurse should understand that the patient is contemplating suicide. In such situations, the nurse should ask the patient directly about suicidal ideation and whether he or she has thoughts of suicide or has developed a plan. The patient is in pain and thus would not be in a happy mood. The patient has not fully recovered yet and may not be discharged soon. Further treatment is required for the patient unless the patient has fully recovered. p. 479

-"What kind of self-injury do you perform?" -"How often do you engage in self-injury?" -"What triggers your desire to hurt yourself?" -"Is there anything that has helped these behaviors in the past?" When performing an assessment on a patient who engages in non-suicidal self-injurious behaviors, the nurse should try to find out about the types of self-injury, what helps the behavior, triggers for the behavior, and frequency of the behavior. It is not therapeutic to ask about the patient's effects on other people, or to think of a time when the behaviors were nonexistent. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 487

-Explaining that strong community and family support is critical -Teaching parents how to use problem-solving and conflict resolution skills in the home -Emphasizing that access to mental healthcare services can help mitigate suicidal ideation Effective mental health services, strong connections to family and community, and problem-solving and conflict resolution skills are protective factors that make it less likely for children to consider, attempt, or die by suicide. Encouraging parents to keep children at home to watch them is not appropriate or feasible. Advising parents to not let their kids use the Internet is also unrealistic. p. 478

Secondary This patient wishes to donate his dead body for medical studies, which indicates that he is having suicidal ideation. Secondary intervention is considered with patients who have suicidal ideation. Secondary intervention is practiced in clinics, hospitals, jails, and on telephone hotlines. Primary interventions are considered in a community to prevent suicide rates, whereas tertiary interventions are conducted with suicide survivors. Postvention is another term for tertiary intervention. p. 482

A sense of responsibility to family Having family responsibilities makes a patient less likely to commit suicide. Hopelessness is the greatest risk factor. Previous attempts are actually a risk factor. Fear of dying or a cultural belief that suicide is a shameful resolution for a dilemma could be protective factors, but they lack the impact of a familial sense of responsibility. p. 478, Box 25.2

Suicidal ideation Suicidal ideation is the term used to describe thinking about death, wishes to die, and methods of accomplishing death. Suicide is not a formal term used in the medical record. It describes the intentional act of killing oneself by any means. Suicide attempt is the behavior of carrying out acts with the intention of death. Completed suicide is a term used to describe actions committed by an individual that lead to death. p. 475

-The woods behind the house is where the suicide will take place. -Patient plans to activate the plan on the anniversary of his divorce. -Jumping from the bridge the next time her voices tell her to kill herself The evaluation of a suicide plan is extremely important in determining the degree of suicidal risk. Three main elements must be considered when evaluating lethality: Is there a specific plan with details? How lethal is the proposed method? Is there access to the planned method? People who have definite plans for the time, place, and means are at high risk. Methods that include overdose and wrist slashing are considered soft or low-risk methods, thus decreasing the lethality of the plan. p. 479

The patient on chemotherapy for breast cancer The nurse should be aware of risk factors and protective factors for suicide. Having a chronic illness like cancer is a risk factor for suicide. A patient who is undergoing treatment for a critical illness like breast cancer is at a high risk of committing suicide. Religious environment acts as a protective factor. Clozapine reduces the risk of suicide in patients with schizophrenia, and lithium reduces the risk in patients with mood disorders. p. 478

Warmth and consistency when interacting Crucial characteristics of staff members who work with suicidal patients include warmth, sensitivity, interest, and consistency. The ability to be consistently organized and the ability to teach problem solving, interview, and counseling skills, although appropriate, are not as important in this situation as consistency. p. 482

Ineffective coping The patient is overwhelmed with stress and consumes alcohol to cope with it. Therefore, the most appropriate nursing diagnosis is ineffective coping with stress. The patient did not give any hints indicating suicide risk. The patient has been going to religious places to relieve stress, which indicates that the patient is not in spiritual distress. The patient is also trying to get a new job and, therefore, has good self-esteem. p. 480, Table 25.2

-Check the patient's mouth after providing doses of the medication. -Advise the patient's family to closely monitor the medication if the dose is taken at home. A tricyclic antidepressant, such as desipramine, can be prescribed to treat depressed patients but the doses should be carefully monitored in suicidal patients. Overdosing on a tricyclic antidepressant can be fatal due to its potent side effects and many suicidal patients attempt suicide by overdose of pills. The nurse should ensure that the patient swallows the tablet by checking the mouth. This will ensure that patients are not hoarding doses of medication with the intention to overdose later. The patient must be given medication only under the supervision of the nurse or the family to avoid overdose. Suggesting the patient increase the dose is not an acceptable option because dosage can only be changed by the primary health care provider and this is not necessarily an action to prevent suicide. The nurse should not give the complete course of medication at one time to the patient as the patient could abuse the drug. Patients must be given a limited day supply of medication so that they cannot consume all the tablets at a time. The nurse should not reduce the dose unless the primary health care provider prescribes it. p. 482

"Actually, it's a myth that asking about suicide puts ideas into someone's head." Asking about suicidal thoughts does not "give person ideas" and is, in fact, a professional responsibility similar to asking about chest pain in cardiac conditions. Talking openly leads to a decrease in isolation and can increase problem-solving alternatives for living. Patients usually have been thinking about suicide already; it is a myth that bringing up the topic will somehow cause someone to become suicidal. Liability is not the reason to ask patients about suicidal thoughts or plans; it is for patient safety. Asking the health care provider to speak to the patient on that subject does not educate the student nurse regarding the need for asking about suicidal ideation and abdicates professional and ethical responsibility for keeping the patient safe. p. 479

-Suicide rates peak in men after the age of 45. -Suicide rates peak in women after the age of 55. -Suicides rates in men are 4 times higher than in women. There are many risk factors for suicide. Age and gender are two of the factors influencing suicidal ideation. Research shows that suicide rates peak after the age of 45 in men and 55 in women. There is also evidence showing that men commit suicide 4 times more often than women. The suicide rates in men peak after 45 years, not 55 years. Suicide rates are greater in women age 55 and above. It is less common in women around the age of 45. Men have a greater suicide rate than women. p. 478