Nursing Diagnosis: Risk for Suicide Application of NANDA, NOC, NIC

Nursing Diagnosis: Risk for Suicide
Gail B. Ladwig

NANDA Definition: At risk for self-inflicted, life-threatening injury

Related Factors:

Behavioral

History of previous suicide attempt; impulsiveness; buying a gun; stockpiling medicines; making or changing a will; giving away possessions; sudden euphoric recovery from major depression; marked changes in behavior, attitude, school performance

Verbal

Threats of killing oneself; states desire to die/end it all

Situational

Living alone; retired; relocation, institutionalization; economic instability; loss of autonomy/independence; presence of gun in home; adolescents living in nontraditional settings (e.g., juvenile detention center, prison, half-way house, group home)

Psychological

Family history of suicide; alcohol and substance use/abuse; psychiatric illness/disorder (e.g., depression, schizophrenia, bipolar disorder); abuse in childhood; guilt; gay or lesbian youth

Demographic

Age: elderly, young adult males, adolescents; race: Caucasian, Native American; gender: male divorced, widowed

Physical

Physical illness; terminal illness; chronic pain

Social

Loss of important relationship; disrupted family life; grief, bereavement; poor support systems; loneliness; hopelessness; helplessness; social isolation; legal or disciplinary problem; cluster suicides

---

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Cognitive Ability

·         Depression Control

·         Distorted Thought Control

·         Impulse Control

·         Self-Mutilation Restraint

·         Suicide Self-Restraint

·         Will to Live

Client Outcomes

·         Does not harm self

·         Expresses decreased anxiety and control of hallucinations

·         Talks about feelings; expresses anger appropriately

·         Obtains no access to harmful objects

·         Yields access to harmful objects

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Anxiety Reduction

·         Coping Enhancement

·         Crisis Intervention

·         Suicide Prevention

·         Surveillance

Nursing Interventions and Rationales

·         Establish a therapeutic relationship with client This study demonstrated the importance of this relationship in identifying and preventing suicide (Rudd et al, 2000).

·         Monitor, document, and report client's potential for suicide. Traits such as impulsivity, poor social adjustment, and mood disorders are associated with adolescent suicide attempts (Brent et al, 1994).

·         Be alert for warning signs of suicide:

o    Verbalizations such as, "I can't go on," "Nothing matters anymore," "I wish I were dead"

o    Becoming depressed or withdrawn

o    Behaving recklessly

o    Getting affairs in order and giving away valued possessions

o    Showing a marked change in behavior, attitudes, or appearance

o    Abusing drugs or alcohol

o    Suffering a major loss or life change

Suicide is rarely a spur-of-the-moment decision. In the days and hours before people kill themselves, there are usually clues and warning signs (Befrienders International, 2001).

·         Assess for suicidal ideation when the history reveals:

o    Depression

o    Alcohol or other drug abuse

o    Other psychiatric disorder

o    Attempted suicide

o    Recent divorce and/or separation

o    Recent unemployment

o    Recent bereavement

o    Chronic pain

Clinicians should be alert for suicide when the above factors are present in asymptomatic persons (National Guideline Clearing House, 2001). This study revealed that clients with chronic pain and depression expressed suicidal ideation (Fisher et al, 2001). The process leading to suicide in young people is often untreated depression (Houston, Hawton, Shepperd, 2001).

·         Refer to mental health counseling and possible hospitalization if there is evidence of suicidal intent, which may include evidence of preparatory actions (e.g., obtaining a weapon, making a plan, putting affairs in order, giving away prized possession, preparing a suicide note).

·         Question family members regarding the preparatory actions mentioned. Clinicians should be alert for suicide when these factors are present in asymptomatic persons (National Guideline Clearing House, 2001).

·         Refer family members and friends to local mental health agencies and crisis intervention centers if client has suicidal ideation or there is a suspicion of suicidal thoughts. Clients at risk should receive evaluation and help (National Guideline Clearing House, 2001).

·         Consider outpatient commitment for actively suicidal client. Involuntary outpatient commitment can improve treatment, reduce the likelihood of hospital readmission, and reduce episodes of violent behavior in persons with severe psychiatric illnesses (Torrey, Zdanowicz, 2001).

·         Counsel parents and homeowners to restrict unauthorized access to potentially lethal prescription drugs and firearms within the home. Identifying teens at high risk of firearm suicide and limiting access to firearms is a type of public health intervention likely to be successful in preventing firearm suicides (Shah, Hoffman, Wake, Marine, 2000).

·         See care plan for Risk for self-directed Violence.

Multicultural

·         Assess for the influence of cultural beliefs, norms, and values on the individual's perceptions of suicide. What the individual believes about suicide may be based on cultural perceptions (Leininger, 1996).

·         With the client's consent, facilitate family-oriented crisis intervention. Family-oriented crisis intervention can clarify stresses and allow assessment of family dynamics (Baker, 1988).

·         Facilitate modeling and role-playing for client and family regarding healthy ways to start a discussion about the client's suicide attempt. It is helpful for families and the client to practice communication skills in a safe environment before trying them in a real-life situation (Rivera-Andino, Lopez, 2000).

·         Identify and acknowledge the stresses unique to culturally diverse individuals. Financial difficulties and maintaining cultural values are two of the most common family stressors cited by women of color (Majumdar, Ladak, 1998).

·         Encourage the family to demonstrate and offer caring and support to each other. The familial characteristics of care and support may be associated with fostering resiliency in African-American families. Resilience is the ability to experience adverse conditions and successfully overcome them (Calvert, 1997).

·         Validate the individual's feelings regarding concerns about current crisis and family functioning. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).