Mental health and psychiatric care plan

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Mental Health and Psychiatric

3 Suicide Behaviors Nursing Care Plans

Suicide is the intentional act of killing oneself. Suicidal thoughts are common in people with depression, schizophrenia, alcohol/substance abuse and personality disorders (antisocial, borderline, and paranoid). Physical illness (chronic illness such as HIV, AIDS, recent surgery, pain) and environmental factors (unemployment, family history of depression, isolation, recent loss) can play a role in the suicide behavior.

Nursing Care Plans

The nursing care plan for suicidal patients involves providing a safe environment, initiating a no-suicide contract, creating a support system and ensuring close supervision.

Here are three (3) nursing care plans (NCP) for suicide behaviors:

1. Risk For Suicide

Risk For Suicide: At risk for self-inflicted, life-threatening injury.

Risk Factors

  • – Alcohol and substance abuse/use.
  • – Abuse in childhood.
  • – Family history of suicide.
  • – Fits demographic (children, adolescent, young adult male, elderly male, Native American, Caucasian).
  • – Grief, bereavement/loss of an important relationship.
  • – History of prior suicide attempt.
  • – Hopelessness/helplessness.
  • – Legal or disciplinary problems.
  • – Physical illness, chronic pain, terminal illness.
  • – Psychiatric illness (e.g., bipolar disorder, depression, schizophrenia).
  • – Poor support system, loneliness.

Possibly evidenced by

  • – Statements of despair, helplessness, hopelessness and nothing left to live for.
  • – Suicide plan (clear and specific, lethal method and available means).
  • – Suicide behavior (attempt, ideation, talk, plan, available means).
  • – Suicide cues
    • – Covert: Making out a will, giving valuables away, writing forlorn love notes, taking out large life insurance policy.
    • – Overt: “No one will miss me”; “No reason to live for”; “I’d be better off dead”.

Desired Outcomes

  • – Patient will refrain from attempting suicide.
  • – Patient will make a no-suicide contract with the nurse covering the next 24 hours, then renegotiate the terms at that time (If in hospital and accepted at your institution).
  • – Patient will remain safe while in the hospital, with the aid of nursing intervention and support (if in the hospital).
  • – Patient will stay with a friend or family if the person still has the potential for suicide (if in the community).
  • – Patient will join family in crisis family counseling.
  • – Patient will have links to self-help groups in the community.
  • – Patient will keep an appointment for the next day with a crisis counselor (if in the community).
  • – Patient will identify at least one goal for the future.
  • – Patient will uphold a suicide contract.
  • – Patient will state that he or she wants to live.
  • – Patient will name at least one acceptable alternative to his or her situation.
  • – Patient will name two people he/she can call if thoughts of suicide recur before discharge.

Nursing InterventionsRationaleIn the Community:Arrange for the client to stay with family or friends. A hospitalization is considered if there is no one is available especially if the person is highly suicidal.Relieve isolation and provide safety and comfort.Encourage the client to avoid decisions during the time of crisis until alternatives can be considered.During crisis situations, people are unable to think clearly or evaluate their options readily.Encourage the client to talk freely about feelings and help plan alternative ways of handling disappointment, anger, and frustration.Gives client other ways of dealing with strong emotions and gaining a sense of control over their lives.Weapons and pills are removed by friends, relatives, or the nurse.To provide a safe environment, free from things that may harm the client.If anxiety is extremely high, or client has not slept in days, a tranquilizer might be prescribed. Only a 1 to 3 day supply of medication should be given. Family member or significant other should monitor pills for safety.Relief of anxiety and restoration of sleep loss can help the client think more clearly and might help restore some sense of well-being.Contact family members, arrange for individual and/ or family crisis counseling. Activate links to self-help groups.Reestablishes social ties. Diminishes sense of isolation, and provides contact from individuals who care about the suicidal person.In the Hospital:During the crisis period, health care workers will continue to emphasize the following four points:

  1. – The crisis is temporary.
  2. – Unbearable pain can be survived.
  3. – Help is available.
  4. – You are not alone.

Because of “tunnel vision“, clients do not have perspective on their lives. These statements give perspective to the client and help offer hope for the future.Forensic Issues:Follow unit protocol for suicide regarding creating a safe environment (taking away potential weapons– belts, sharp objects, items, and so on).Provide safe environment during time client is actively suicidal and impulsive; self-destructive acts are perceived as ties, the only way out of an intolerable situation.Keep accurate and thorough records of client’s behaviors (verbal and physical) and all nursing/physician actions.These might become court documents. If client checks and attention to client’s needs or request are not documented, they do not exist in a court of law.Put on either suicide precaution (one-on-one monitoring at one arm’s length away) or suicide observation (15-minute visual check of mood, behavior, and verbatim statements), depending on level of suicide potential.Protection and preservation of the client’s life at all costs during crisis is part of medical and nursing staff responsibility. Follow unit protocol.Keep accurate and timely records, document client’s activity, usually every 15 minutes (what client is doing, with whom, and so on). Follow unit protocol.Accurate documentation is vital. The chart is a legal document as to client’s “ongoing status,” intervention taken, and by whom.Encourage the client to talk about their feelings and problem solve alternatives.Talking about feelings and looking at alternatives can minimize suicidal acting out.Construct a no-suicide contract between the suicidal client and nurse. Use clear, simple language. When the contract is up, it is renegotiated (If this is accepted procedure at your institution).The no-suicide contract helps client know what to do when they begin to feel overwhelmed by pain (e.g., “I will speak to my nurse/counselor/support group/family member when I first begin to feel the need to end my life”).

2. Ineffective Coping

Ineffective Individual Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.

May be related to

  • – Disturbance in pattern of tension release.
  • – Impulsive use of extreme solutions.
  • – Inadequate coping skills.
  • – Inadequate social support created by characteristics of relationship.
  • – Inadequate resources available.
  • – Inadequate opportunity to prepare for a stressor.
  • – Personal loss or threat of rejection.
  • – Poorly developed social skills.
  • – Situational or maturational crises.

Possibly evidenced by

  • – Abuse of chemical agents.
  • – Change in usual communication pattern.
  • – Decreased use of social supports.
  • – Destructive behavior toward self or others.
  • – Expression of anxiety, depression, fear, impatience, frustration, and/or discouragement.
  • – Inability to meet basic needs.
  • – Inability to meet role expectations.
  • – Inability to problem solve.
  • – Lack of goal-directed behavior.
  • – Poor problem solving.
  • – Use of forms of coping that might impede adaptive behavior.
  • – Verbalization of inability to cope or inability to ask for help.

Desired Outcomes

  • – Patient will refrain from using or abusing chemical agents.
  • – Patient will reports adequate supportive social contacts.
  • – Patient will state that he or she feels comfortable with one new coping technique after three sessions of role playing.
  • – Patient will discuss with the nurse/counselor at least three situations that trigger suicidal thoughts, as well as feelings about these situation.
  • – Patient will name two effective ways to handle difficult situations in the future.
  • – Patient will state willingness to learn new coping strategies (through group, individual, therapy, coping skills training, cognitive-behavior skills and so on).
  • – Patient will name two persons to whom he/she can talk if suicidal thoughts recur in the future.
  • – Patient will state that she or he believes his/her life has value and that they have an important role to play (mother, son, huband, father, provider, friend, job-related position, etc).
  • – Patient will demonstrate two behaviors in dealing with emotional pain.
  • – Patient will demonstrate a reduction of self-destructive behaviors.

Nursing InterventionsRationaleAssess client’s strengths and positive coping skills (talking to others, creative outlets, social activities, problem-solving abilities).Use these to build upon and draw from in planning alternatives to self-defeating behaviors.Assess client’s coping behaviors that are not effective and that result in negative sequelae:

  • – Angry outbursts.
  • – Denial.
  • – Drinking.
  • – Procrastination.
  • – Withdrawal.

Identify areas to target teaching and planning strategies for supplanting more effective and self-enhancing behaviors.Assess need for assertiveness training. Assertiveness skills can help client develop a sense of balance and control.When people have difficulty getting their needs met or asking for what they need, frustration and anger can build up, leading to, in some cases, ineffective outlet for stress.Identify situations that trigger suicidal thoughts.Identify targets for learning more adaptive coping skills.Clarify those things that are not under the person’s control. One cannot control another’s actions, likes, choices, or health status.Recognizing one’s limitations in controlling other is, paradoxically, a beginning to finding one’s strength.Assess client’s social supports.Have client experiment with attending at least two chosen possibilities.

3. Hopelessness

Hopelessness: Subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on his/her own behalf.

May be related to

  • – Abandonement.
  • – Chronic pain.
  • – Failing or deteriorating physiologic conditions (Cancer, AIDS).
  • – Long-term stress.
  • – Lost belief in transcendent values/God.
  • – Loss of significant support systems.
  • – Perceived hopelessness, helplessness.
  • – Perceiving the future as bleak and wasted.
  • – Prolonged isolation.
  • – Severe stressful events (financial reversals, relationship turmoil, loss of job).

Possibly evidenced by

  • – Decreased affect.
  • – Decreased judgment.
  • – Decreased problem solving.
  • – Impaired decision making.
  • – Lack of initiative.
  • – Lack of involvement in care.
  • – Lack of motivation.
  • – Loss of interest in life.
  • – Passivity, decreased verbalization.
  • – Turning away from speaker.

Desired Outcomes

  • – Patient will express the will to live.
  • – Patient will have an expression of positive future orientation.
  • – Patient will have an expression of meaning in life.
  • – Patient will make two decisions related to his/her care.
  • – Patient will identify three things that he/she is doing right.
  • – Patient will reframe two problem areas in his/her life that encourage problem-solving alternative solutions.
  • – Patient will identify two alternatives for one life problem area.
  • – Patient will name one community resource (support group, counseling, social service, family counseling) that he/she has attented at least twice.
  • – Patient will state three optimistic expectations for the future.
  • – Patient will describe and plan for at least two future-oriented goals.
  • – Patient will demonstrate two new problem-solving skills that client finds effective in making life decisions.
  • – Patient will demonstrate reframing skills when viewing aspects of client’s life that appear all negative.

Nursing InterventionsRationaleEncourage clients to look into their negative thinking, and reframe negative thinking into neutral objective thinking.Cognitive reframing helps people look at situations in ways that allow for alternative approaches.Work with client to identify areas of strengths.When people are feeling overwhelmed, they no longer view their lives or behavior objectively.Point out unrealistic and perfectionistic thinking.Constructive interpretations of events and behavior open up more realistic and satisfying option for the future.Identify things that have given meaning and joy to life in the past. Discuss how these things can be reincorporated into their present lifestyle (e.g., religious or spiritual beliefs, group activities, creative endeavors).Reawakens in client abilities and experiences that tapped areas of strength and creativity. Creative activities give people intrinsic pleasure and joy, and a great deal of life satisfaction.Spend time discussing client’s dreams and wishes for the future. Identify short-term goals they can set for the future.Renewing realistic dreams and hopes can give promise to the future and meaning to life.Encourage contact with religious or spiritual persons or groups that have supplied comfort and support in client’s past.During times of hopelessness people might feel abandoned and too paralyzed to reach out to caring people or groups.Teach client steps in the problem-solving process.Stress that it is not so much people are ineffective, but rather it is often the coping strategies they are using that are not effective.

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