Nursing Suicide Risk Assessment Quiz

Psychiatric Mental Health Nursing: The Client Who Is Suicidal

• Suicide is the purposeful taking of one's own life, the ultimate form of self-destruction, involving intense feelings of fear, loss, anger, or despair.
• The effects of suicide can be devastating and long-lasting.
• Nurses must recognize suicidal risk, as suicide causes 11 deaths per 100,000 people per year.
• Suicide is preventable.

Learning Outcomes

• Identify conditions and circumstances that make individuals at high risk for suicide.
• Describe a means of assessing suicide potential in a client.
• Know the means of providing a safe environment for the suicidal client.

Guam's Suicide Rates

• Suicide is the 8th leading cause of death on Guam.
• Every 6 days, someone dies by suicide on Guam.
• 2019: 31 deaths (20-30 year olds)
• 2018: 44 deaths (30-40 year olds)
• 2010: 30 deaths from suicide
• 2011: 7 cases, 4 were 16-year-olds
• Illicit drug use is a contributing factor.

Suicide Statistics

• Suicide is the 10th leading cause of death for people aged 15 to 24.
• The suicide rate for males over 75 years old is three times the national average.
• The suicide rate is 40% higher among the elderly.
• Suicide is more common in divorced and separated men.

Myths About Suicide

• People who talk about suicide never commit it.
• People who are suicidal only want to hurt themselves, not others.
• There is no way to help someone who really wants to kill himself.
• Mentioning the word suicide will cause the suicidal individual to actually commit suicide.

Main Priority: Safety

• Safety is the highest priority when working with suicidal clients.
• Suicide precautions are crucial to prevent self-inflicting injuries or death.

Suicide Potential Assessment

• Suicide potential is assessed using the rationality of the client, their plan, and the means of carrying it out.
• Table 16-1 Assessment of Suicide Potential is helpful.
• The SAD PERSONS tool (Handout) is a useful assessment method. -A helpful website is https://qxmd.com/calculate/calculator_201/modified-sad-persons-scale

Suicide Risk Assessment (SAD PERSONS)

• Details for the SAD PERSONS tool are included in page 9.

Clinical Action Based on SAD PERSONS

• Clinical actions, like sending the client home with follow-up, close monitoring, or hospitalization, depend on the total points from the SAD PERSONS tool.
• Details are included in page 10.

Suicide Attempts

• Some accidents may be suicides.
• Suicide attempts (unsuccessful) are more common in women.
• Successful suicides are more common in men.
• Suicidal ideation (thoughts of suicide) must not be ignored.
• Many suicide attempts involve firearms and/or medication overdoses.

Suicide and Psychiatric Illnesses

• 90% of those who commit suicide have a psychiatric diagnosis.
• Unipolar (persistent sadness) and bipolar depression are among the conditions at higher risk.
• Schizophrenia increases suicide risk.
• Alcohol and substance abuse increase suicide risk.

Recognizing Signs and Symptoms

• Depression is the most common sign.
• Look for sudden changes in behavior (reckless, withdrawn, talking about death).
• Observe dramatic mood changes.
• Monitor for improved mood post anti-depressant therapy (medication may not be therapeutic yet).

Formulation of a Suicide Plan

• Look for signs like giving away possessions, accessing lethal means (weapons, pills), getting finances in order, and direct/indirect statements of suicidal intent.
• Increased energy, a suicide note, and a plan for committing suicide are all significant signs to watch out for.

Risk Factors for Suicide

• Males over 50 years old are at high risk.
• Suicide is the 2nd leading cause of death for 15-19 year olds.
• Social isolation is an important factor.
• A history of previous suicide attempts is a high-risk indicator.
• Terminal illness increases risk.
• Job or financial loss can be a contributing factor.
• Mental health issues, drug/alcohol abuse, and depression all significantly increase suicide risk.

NCLEX Considerations

• To assess suicide risk, determine if a plan exists, the lethality of the plan, and the client's access to the means.
• Evaluate the presence and lethality of the plan, and assessment of means will guide treatment.

Warning Signs

• Clients emerging from depression may have increased energy to plan suicide.
• A sudden change from depressed mood to cheerful or motivated behavior in a depressed client is a strong warning sign and indicates an increased risk for suicide.

Care of Suicidal Clients

• The immediate focus is on client safety.
• One-on-one supervision and support are critical.
• Establish trust through non-judgmental communication.
• Remove all potential means of self-harm in the environment (belts, razors).
• Use caution in the use and prescription of pills to ensure safety.

Always 1:1 Supervision

• Clients should be on 24/7 supervision to prevent self-harm.
• Monitor client's access and use of harmful means.
• Staff check on clients regularly (every hour) and document the monitoring.

Danger Times

• Periods in a hospital environment when staff may be less available for observation (shift change, weekends, nightshifts)

If a Suicidal Client Calls

• Keep the caller speaking with them while getting help for them.
• Be sympathetic and non-judgmental.
• Listen and keep calm.
• Try to get details of any ingested substance and the amount.
• Avoid advising, belittling, or making quick referrals.

Duty of Care

• Healthcare professionals have a legal responsibility to ensure reasonable care in preventing a client from dying by suicide if aware of their risk.

Social Media-Suicide

• Cyberbullying is a significant factor, increasing suicide risk among children and adolescents.
• Cyberstalking is a similar contributing factor for adults.
• In some cases, suicides are committed in reaction to cyberbullying.

Special Populations

• Adolescents and young adults are at high risk for drug-related suicide attempts.
• Elderly individuals, may have experienced losses, alcohol use, and loneliness.
• Incarcerated individuals are at a higher risk for suicide compared to the general population.
• Military combat veterans are also among those who are at risk for suicide.

Suicide Survivors

• Friends and family members of those who committed suicide may have an increased burden of stress and experience grief in different ways.
• They may experience anger and sadness, and need support after losing a loved one to suicide.
• Nurses may need to support those who have lost loved ones to suicide.

Nursing Diagnosis

• Spiritual well-being or distress
• Hopelessness
• Powerlessness

Outcome Identification

• The goal is to prevent harm, develop a suicide safety plan, ensure client safety, and create a safe and reduced-risk environment.

Suicide Safety Plan

• A written plan, developed with the client's help and support, offering specific steps the client should take if they feel suicidal.
• A safety plan may include warning signs, steps to isolate themselves, reasons for living, and resources of contact.

Planning/Interventions

• Prevention strategies should include primary (public awareness, especially in young people), secondary (early recognition of suicide risk factors), and tertiary (preventing additional suicide attempts and supporting survivors).
• Control access to means of harming oneself or others.
• Media responsibility must address harmful content.
• Crisis intervention and maintaining communication with the client is crucial.

Further Planning and Interventions

• Encourage hospitalization if necessary.
• Help the client develop a suicide contract.
• Decrease the client's social isolation.
• Minimize psychological symptoms through measures to manage anxiety and stress.

Evaluation

• Prevent harm through monitoring and support.
• Assess the client's view of their self and life situation.
• Evaluate the restoration of hope.
• Involve family members and significant others to gain support and reinforce safety efforts.
• Ensure evaluation of the client's care.

Case Study: Crisis Hotline Call

• The best initial response by a nurse to a hotline caller stating "It's over" is to ask "Are you thinking of hurting yourself?"
• This is the most important and direct question as it is the central concern and the highest priority.

Therapeutic Response

• Nurses need to get to the point quickly when interacting with a client at risk of self-harm.
• The crucial question to ascertain is whether a clear plan is present for harming oneself.