3.8 Spotlight Application
Let’s review how the nursing process can be applied to Sample Case A introduced earlier in the chapter regarding caring for a suicidal patient:
Recognizing Cues
During an interview with a 32-year-old male patient diagnosed with Major Depressive Disorder (MDD), the patient exhibited signs of a sad affect and hopelessness. He expressed desire to die and reported difficulty sleeping and a lack of appetite. He reports he has not showered in over a week and his clothes have a strong body odor. The nurse has received report from the previous shift, checked for abnormal laboratory results, and reviewed the characteristics of MDD.
Analyzing Cues and Generating Hypotheses
The nurse analyzed this data and created four nursing concerns:
- Risk for Suicide as manifested by the reported desire to die
- Hopelessness
- Imbalanced Nutrition
- Self-Neglect related to insufficient personal hygiene
All of these cues/hypotheses can be linked with Major Depressive Disorder. The nurse established the top priority nursing diagnosis of Risk for Suicide and immediately screened for suicidal ideation and a plan.
Generating Solutions
The nurse determines that a trusting relationship will be required in order to promote verbalizing emotions and collaborating on plans. The nurse anticipates that an antidepressant medication will be ordered and the patient will need basic education. The patient is at high risk for self-harm and suicide, so the nurse will inform the staff that the patient should receive Q-5-minute safety checks and removal of dangerous items from the patient’s possession. The patient needs nutritious foods and encouragement to eat. The nurse identified the following SMART expected outcomes:
- The patient will begin verbalizing feelings to the nurse by the end of the shift.
- The patient will remain free from injury during the hospitalization stay.
- The patient will progressively gain at least one pound per week toward his ideal body weight (180 pounds).
- The patient will participate in daily bathing by end of week.
Taking Action
- The nurse reviewed information for the prescribed antidepressant and safely gave the medication.
- The nurse used therapeutic communication techniques to increase trust during conversations with the patient.
- A complete assessment of suicidal risk was performed.
- The staff performed a room check for dangerous items and is observing the patient every 5 minutes.
- The patient has been offered meals and snacks.
- The nurse brought a towel and washcloth to the patient and encouraged a shower.
Evaluation
Day 1: Outcomes partially met. By the end of the shift, the patient verbalized feelings related to hopelessness and did not harm himself. He did not agree to participate in taking a bath and only ate 25% of his meal tray. Actions will be re-attempted on Day 2 and reassessed for effectiveness.
Sample Documentation
0900: 32-year-old male patient diagnosed with Major Depressive Disorder admitted for active suicidal ideation with a plan to do so with a gun. He has the means to accomplish this plan at home. He has expressed the desire to die and reports difficulty sleeping and a lack of appetite for the past two weeks. He reports he has not showered in over a week, and his clothes have a strong body odor. Patient was placed in a room near the nursing station and assigned Q 5 min checks. His personal belongings were removed and placed in a secure area. An environmental scan was completed, and all hazards were removed from the room. harm contract. Dr. Delgado assessed the client at 0945, and new orders for medications were received and administered. —– Zerimiah Alimi, Nursing Student
Questions for Reflection
- How can the nurse assess whether the patient is free of self-injury?
- Once the patient’s suicidal ideations subside, what is the next priority? Why?
